DOSS It Matter? (Spoiler: Yes.)

Speaker0:
[0:16] I'm Emily.

Speaker1:
[0:17] And this is Eva.

Speaker0:
[0:18] And you're listening to Speech Talk.

Speaker1:
[0:21] We're your research book club so you can do evidence-based practice in practice.

Speaker0:
[0:25] So let's get talking.

Speaker1:
[0:27] All right, moments from this week, Emily. What happened?

Speaker0:
[0:30] So I was giving the mocha, and you know the part where they're like, name as many F-words as you can in a minute. And the person I was evaling is like... You know, the one, can I say the one? And I'm like, yeah, go ahead. We're all adults here. They go, fornicate. I'm like, okay, that one too. That's Elsa.

Speaker1:
[0:54] It's better than having the F word thrown at you in the context of Mocha.

Speaker0:
[1:00] I know they asked for permission. It was a cute moment. What about you, Eva? What's your funny moment from this week?

Speaker1:
[1:05] Something really hilarious. We have a COVID outbreak.

Speaker0:
[1:07] Oh, what? That's not funny.

Speaker1:
[1:10] No, it's not. It is not funny. Everything takes extra long. And I'm constantly like wondering how many times I have to shower when I get home.

Speaker0:
[1:22] And you have a new baby.

Speaker1:
[1:23] My family. Yeah. And I've got the baby. I know. Anyways, that's my laugh.

Speaker0:
[1:29] That's a depressing laugh. That is a sniff laugh. It's like,

Speaker0:
[1:33] oh, we're sick again. What is my life?

Speaker1:
[1:37] Well, I have something to tell you, Emily. It's a confession. It's something I really learned about myself. I am not a consistent person. I do my recipes differently every time. I can't commit to like one type of scrubs.

Speaker1:
[1:50] And my eval notes vary every single time in how well I can describe a patient's swallow function. And I'm not the only person who's inconsistent. I certainly do not agree with how other clinicians are describing my patient swallows when we get like PRN folks in. What we need is standardization, and that is what we're here to talk about today. Ah!

Speaker0:
[2:13] The golden light.

Speaker1:
[2:14] The golden ah of standardization. I love that.

Speaker0:
[2:19] So the article this week is titled Dysphagia Outcome and Severity Scale, and it was authored by Karen O'Neill, Mary Purdy, Janice Falk, and Janelle Gallo. And you guys have a lot of letters after your name.

Speaker1:
[2:35] Yeah folk that's also an f word

Speaker0:
[2:39] And the goal of this article was to develop. And yes, we say develop because this article is old as dirt. This is in the 90s. Some of you guys weren't even born yet. You know, I hear that all the time. Like, oh, you were born in the 1900s. Like, yeah, girl, I'm old.

Speaker1:
[3:00] Get out of here. Been here. Yes. When dirt was invented in 1999.

Speaker0:
[3:05] I'm older than the Internet. That's my favorite thing to tell my kids. I'm older than the internet. Anyways.

Speaker1:
[3:11] Don't even know what that means.

Speaker0:
[3:13] This article, it was developed in 1999 to be a reliable, consistent, and valid assessment based on a need to provide a rationale to prove a need for dysphagia therapy. Because people dying on food is not enough. We have to further prove to the people and the insurance companies that we can do something to help.

Speaker1:
[3:34] We can. That's what I tell myself every day. I'm helpful. I'm helpful. I'm useful. They also wanted to include more objective components in the scale in order to enhance a rater ability to identify patterns that are beneficial or hindrances to treatment therapy.

Speaker0:
[3:53] It's important because dysphagia is common. About 25 to 45 percent of our stroke patients have some kind of dysphagia and about 40 percent of our nursing home residents do have a dysphagia.

Speaker1:
[4:07] Yeah. And as I like to say, 40 sounds a lot like 50, so close to half.

Speaker0:
[4:13] Which sounds like 60, which sounds like 70.

Speaker1:
[4:17] I know, it just keeps growing when you start thinking intense. All right, so we wanted to look into dysphagia scales and the best way to indicate severity because we got to be on the move and we got to be able to put numbers to things to show progress. So looking at the DOS, if you haven't heard of it, it's a seven-point dysphagia scale going from NPO through modified diets to full PO that incorporates indicators for nutrition levels, diet texture recommendations, and independence factors. We're going to get into what those mean and why it's such a great tool for clinicians.

Speaker0:
[4:52] So this is an article I wanted to do because back at my old facility when I was working with trachs and vents and a lot of tube feeds, this was something that I used a lot. It was one of my very first badge buddies. And the more you know, I lost it. So I'm going to remake it for you guys because it was beautiful. But it really helped me categorize my dysphagia patients, right? Not all of my NPO patients were created equal. Not all of my two patients were the same. So I really wanted to look at the nuances of what they were doing. And this number scale made it really, really easy. So the DOS had really good inter-rater reliability. It was useful for demonstrating.

Speaker1:
[5:41] Love intervals.

Speaker0:
[5:42] You just love it.

Speaker1:
[5:44] I just love it. Sorry. Love inter-raider reliability. So important. Carry over matters.

Speaker0:
[5:52] So when all of the raiders understand what's going on, it means that we all can talk about something in the exact same way. And we're not, doing guessing games. Everybody wants to be able to say for sure that this person demonstrates X and not have to think about it, not have to be like, what do you think? Well, what do you think? So that's great. And that, again, is useful for the third-party payers that the patient's therapy is warranted. And while the article doesn't actually say this, we found that looking in depth at how the DOS is structured, it gave us a great way to build goals and develop a plan of care.

Speaker1:
[6:30] So now let's jump into what that one through seven looks like. Number seven, a normal swallow, a normal diet. Going down to number six, you got some mild issues, but you compensate independently. You may need extra time. I feel like I'm getting a little more old lady Jewish New York as I get

Speaker0:
[6:49] Down the scale. I don't know.

Speaker1:
[6:52] But I'm going to keep going. I'm going to swap back into that strange decision I made. Number five, mild dysphagia. You need distance supervision and maybe one diet restriction. Number four, mild to moderate. You need intermittent cues, one to two diet restrictions, you know? Number three, moderate. You need a total assist, multiple restrictions. I don't know if you guys think this is interesting, but a moderate is a total assist. Number two. I can't do it anymore.

Speaker0:
[7:29] No, keep going. I'm like dying over here.

Speaker1:
[7:32] Moderately severe. You need maximum assistance and you may only tolerate one consistently safely, consistency safely and one severe NPO. Now, if I had to tolerate one consistent safely, it would be my afternoon glass of wine. Okay.

Speaker0:
[7:56] Oh, my God. That was wonderful. Okay.

Speaker1:
[7:59] Thank you.

Speaker0:
[7:59] I loved it. Oh, my gosh. No, that was great. Okay.

Speaker0:
[8:05] Two, not such a perfect accent. So to recap, seven, totally normal, nothing wrong. Six, your mod eye. Don't need a lot of help. Five, mild. Four, mild mod. Three, moderate. Two, moderate, severe, one, severe, and PO.

Speaker1:
[8:24] The number three, really though, the moderate is interesting, needing a lot of assistance because, you know, I think of somebody who has moderate swallow difficulties. I may see that and go, oh man, they need a lot of help. Somebody else might see that and go, you know, there's like a moderate amount of difficulty in the oral phase, but once they swallow it, they're doing fine. So maybe moderate oral dysphagia and they rate them as moderate. That doesn't necessarily mean that globally in terms of their function, they're moderate. That sounds way closer to independent using the DOS scale if they're aware of their moderate oral difficulties and can maybe strategize around it. So, you know, a C in this case, like a someone who needs quite a bit of help.

Speaker0:
[9:17] You do need a lot of help on a moderate. Like moderate does sound like, oh, kind of in the middle. It's not too bad. You might need 50%. But when it comes to terms in dysphagia, needing 50% assistance is a lot of assistance.

Speaker1:
[9:33] It's a lot of assistance.

Speaker0:
[9:34] So the scale is determined by an intersection of three categories. We have nutrition, diet recommendations, and independence levels. Eva, what does that mean?

Speaker1:
[9:47] So our nutrition, pretty simple. Are they PO or NPO? Can they eat or can they not eat? They're diet recommendations. Can they eat regular or do they need altered consistencies? If so, to what extent? And independence, can the person cognitively identify the need to alter or learn strategies and decrease their signs and symptoms of dysphagia. We love independence. We love being able to talk about that cognitive intersection because predominantly with our declining folks, that is a lot of times going to be the underlying thing that changes, not just muscle tone and coordination, but awareness of food. Is it coming out of their mouth? Is it still in their mouth? Where's the food?

Speaker0:
[10:38] And what is a good bite size i've spent you know too many sessions saying what is a small bite and you're like oh no and put take a big old shovel to the face and then keep going i was like no love.

Speaker1:
[10:52] A good shovel to the face

Speaker0:
[10:53] Low down quarter yeah nothing bigger than a quarter oh.

Speaker1:
[10:59] That's a really good visual metric i'm gonna use that i always learn something from you emily This is secretly why we hang out.

Speaker0:
[11:05] No, that's always my thing. And if they're like really bad, I think it's quarter for normal. And then I go dime if they really need super small bites. Like we were looking for dime pieces when they were struggling.

Speaker1:
[11:19] Looking for a dime.

Speaker0:
[11:21] So the article also mentioned an additional factor, which was environment. So it wasn't one of the levels that they put the scale on. So it's not a testing factor. quote unquote, but it was taken into consideration for assigning levels. So environment is the level of supervision the person can realistically expect to have. So if you have a restorative dining room that provides queuing and assistance and allows that person to stay in a highly supervised environment without you there coaching them all the time, then maybe they can have more access foods than if everybody is expected to eat alone in their rooms, right? So if their environment is extremely supportive, then they can maybe do more.

Speaker1:
[12:13] And I really like how you phrase that because that's on my mind right now with our COVID outbreak. You know, people who typically have access to the activities room or other shared eating spaces and can have more support. Now, if they want to continue on their diet, it would need one-to-one support. And that's really hard to provide when everyone's essentially on isolation. Not literally, but we're really trying to encourage people to stay in their rooms and avoid common spaces, particularly if they're unmasked,

Speaker1:
[12:50] like you would be at meals. So taking that into consideration, this person typically does well with distant supervision, but while we're on COVID precautions, we should be giving that person more attention or seeing if they need a temporary downgrade just to get through this period where they're alone and they don't have as much access to one-to-one support.

Speaker0:
[13:15] Yeah, and that's such a tricky situation because we can't write an order for that, right?

Speaker1:
[13:20] It would be very long orders, like patient on mod I to downgrade to generally moderate needing one-to-one support if left alone in their room during mealtimes. Like, no one's doing that.

Speaker0:
[13:35] In the case of a pandemic, what is this world we live in, honestly? What is this? So after making this beautiful scale, they tested it. They used 135 people varying from no clinical sign of dysphagia to severe dysphagia. The raters were SLPs who had undergone DOS training. After the training, they were asked to rate the patient's dysphagia on the seven-point scale from MBS study recordings. There were three judges who rated participants blindly. Out of the 135 participants rated, 90% were rated on the same scale.

Speaker1:
[14:17] Nine out of 10 agreement.

Speaker0:
[14:20] That's awesome.

Speaker1:
[14:22] Awesome. I don't even agree with myself that often.

Speaker0:
[14:26] They said the only limitation really was that some of what skewed the raters were the amounts when identifying retention in the oral cavity or the pharynx. So like how much was, like is it a trace amount, mild amount? I feel like when we took that MBS course, that was a tricky thing to say. What was traced? What was mild? How much is in there?

Speaker1:
[14:50] Yeah, definitely. The inter-rater reliability is really important. I know that we all have had PRN substitutes. And if they're seeing changes or taking on evals while we're gone, sometimes the way that they are reading the patient's bedside swallow is going to differ from how I would have seen it because people come from different backgrounds. When I am looking at bedside swallow, I'm looking for general safety. I'm like, if you got some residue on your tongue or you have a little bit of a gurgly throat, but you can clear it really well independently, it doesn't bother me too much. But other people hear a gurgly throat and they're like, this is serious. We got to get all up in there. And being able to have something that you can put a number to and define why it is that number because the rating system is so clear, I think really does help that trade-off. And we need to be able to ensure continuity of care. Hard to do if you don't have a standard way of communicating.

Speaker0:
[15:57] Yeah. And I love that to be able to give that to your PRN girls and say, hey, if I have a COG patient, base them off of the MOCA or the BCAT or whatever you use. If I have a DeSwallow patient, base it off the DOS so that they're not giving you crazy goals. I once had a PRN girl gave me six long-term goals and six short-term goals, and each of the goals were the same, and they related exactly to all things. And I'm like, friend, I know I needed you, but now I have to redo this whole eval. I don't know how much help this was.

Speaker1:
[16:34] Yeah, definitely. Definitely have had those types of issues.

Speaker0:
[16:37] So this at least can give you that basis to say, this is how I need this. This is how I like the goals. So they don't have to put a lot of thought into it either.

Speaker1:
[16:49] All right. Well, let's move into how this is good for us as clinicians, aside from everything we've just covered. This joint is billable. We all know insurance companies love numbers. And to play their part, you know, unfortunately, there are a lot of people who are are just there to show up, see a patient and leave. And they're not really looking out for when the patient can come off of therapy. They're not really concerned about if they've maxed out, if there's room for progress. And so people can just keep getting billed. So we want to be able to show when a person is making progress, we're showing an escalation on a scale and insurers love to see that. We love to see that for our patients. And frankly, it's a good accountability measure.

Speaker0:
[17:39] Yeah. And it's so good to be able to say like, look, my patient was a two and now they're at a three or a four. Or even if it's taking a little bit longer, you can say this person has gained this amount of independence, progressing them towards this next level. So you can still have those intermediary steps, even if they haven't met like that whole next number. Again, you know, some of our, I mean, our patients are typically chronically ill and they're not progressing at a super fast rate. So if we are able to say, this is progress, then this is progress. We can say on a scale, this is how much they're doing better. And I can prove it to you through these numbers.

Speaker1:
[18:25] And always highlighting that to your patient being like, I know it feels like you've been here for forever and the lights don't always work. So sometimes it feels like it's an endless night, but you're making progress. You went from five to seven or you went from two to six, you know, good job. You're working.

Speaker0:
[18:46] And this is a great tool because it does, it doesn't require anything extra. So when you're completing it, it's you're doing all of your regular things. You're testing their swallow. You're asking them to cough. You're doing the throat clears. You're giving them those informal cognitive tests. So all of these things you can use to, place them on the DOS? Like, where exactly are they fitting in on that scale?

Speaker1:
[19:12] Yeah. And to that point about independence in, you know, cognitive function being integrated into the DOS, there's, you know, if they can remember who you are from the beginning to the end or remember a technique you tell them at the beginning of your evaluation session all the way at the end. This sounds like they're going to be stimulable for strategies, which makes them more functional and more stimulable for therapy. Great prognostic indicator. I'm glad we're learning about that for our patients.

Speaker0:
[19:47] Like we were saying earlier too, so use this to create goals. So not just for your PRN girls, but for yourself too. Girls are guys.

Speaker1:
[19:58] Girls are guys. Yes. We know it's heavily female field, but there are boys out there.

Speaker0:
[20:03] We see you.

Speaker1:
[20:04] Hey, guys.

Speaker0:
[20:07] Yeah. So you can like you could put it in your goal. So it's moving up. It's giving you that easy basis. So you don't have to you don't have to think about your goal so heavily. They're a four. Cool. We want them a five. They're a five. Cool. What is that next step? What is realistic?

Speaker1:
[20:24] Yeah, I love that. And I don't know how your facility works, Emily, but in mind, we have to do weekly progress notes. So it can feel like, how are we breaking down this overall dysphagia goal? We're going up one scale at a time. And if maybe an entire scale jump isn't easy, we can at least say, hey, we want them to be more independent on a level six, or we want them to, what else could we say? Go from like two to three altered diets to one to two because of how the scale is structured. It can allow us to make these kind of marginal gains within an overall category.

Speaker0:
[21:06] Yeah. So for you, our lovely listeners, we will, I will remake my badge, buddy.

Speaker0:
[21:17] It was so beautiful the first time. I hope it'll be nice the second time. Um, so that you guys can use it. You can put it on your badge or you can keep it at your desk. So it's easily referenceable.

Speaker1:
[21:30] Yeah. And remember that this is something we can always talk to our peers about. So if you are the lead SLP, see if you can get your teammates on it. And if you're a PRN SLP, try throwing that into an eval to make things a little more salient for your, you know, in-house SLP when they get back to read your notes on.

Speaker0:
[21:52] This might also be something that you can talk to your facility about, right? Like if the level of supervision is just not well enough that your patients are getting stuck at a four or five, talk about implementing a restorative dining program. See if we can get some of the STNAs trained on feeding and swallowing compensations to increase safety. Everybody wants to be helpful and everybody like wants to feel smart and needed and like having your, you know, your STNA specialized in your, your, your feeding education only makes like them feel better, the facility feel better. It just, and it looks good. It looks good to have your aides and everybody supporting the residents who live there. It's beautiful.

Speaker1:
[22:45] Definitely. I know my activities lead is always asking me for stuff about communication and dysphagia because he oversees the communal dining areas. He's always like, let me know what I can help out with, what I can keep an eye on. And I check in with him regularly because he does see like 10 residents at a time. And while he's not literally feeding 10 residents at a time, he is able to certainly by the like within a week, let me know if anyone has had any difficulties. So just telling that person like, hey, these are the types of things we like to keep an eye on. Does it seem like they're having a hard time with their meals does it seem like they're not as independent as maybe they were with self-feeding just let me know what you're saying i like that emily that team approach you're such a good team

Speaker0:
[23:38] And you're always making me blush. You're always good with the confidence.

Speaker1:
[23:42] It's, I think that time, Emily. I think it's time to wrap up.

Speaker0:
[23:46] Well, until next time, keep your therapy functional and your notes short.

Speaker1:
[23:50] May the force be with you.

Speaker0:
[23:52] Thanks for listening, guys. You've been listening to Speech Talk.

Speaker1:
[23:56] Thank you, everyone, for coming to listen to our research book club. Until next time, keep learning and leading with research.

Speaker0:
[24:02] If you like this episode and you want to give us some love, please rate us on your favorite podcasting app. Leave a review and tell the world, because as podcasters, our love language is in positive affirmations.

Speaker1:
[24:14] If you have a research topic you want us to cover, or you have episode comments, clinical experience you want to share, or just want to send us some love letters, send us an email at hello at speechtalkpod.com.

Speaker0:
[24:27] If you want even more speech talk content, check out our website at speechtalkpod.com, where you can find all of our resources we made for you, copies of articles covered, and Eva's blog following these topics and more.

Speaker1:
[24:40] We're your hosts, Eva Johnson and Emily Brady.

Speaker0:
[24:43] Our editor and engineer is Andrew Sims.

Speaker1:
[24:46] Our music is by Omar Benzvi.

Speaker0:
[24:48] Our executive producers are Aaron Corney, Rob Goldman, and Shanti Brooke.

Speaker1:
[24:52] To learn about Speech Talk's program disclaimer and ethics policy, verification and licensing terms, and HIPAA release terms, you can go to speechtalkpod.com slash disclaimers.

Speaker0:
[25:04] Speech Talk is a proud member of the Human Content Podcast Network.