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Fibreoptic endoscopic evaluation (FEES)

Fibreoptic endoscopic evaluation (FEES)

Clinical application of Fibreoptic Endoscopic Evaluation (FEES) in the assessment and management of dysphagia.


What is dysphagia?

Many patients admitted to hospital experience difficulty swallowing (dysphagia).  The incidence of dysphagia is much higher in the elderly population, which is a large percentage of North Shore and Waitakere Hospital’s population.

Dysphagia is also significantly higher in certain disorders: as many as 80% of stroke patients and 60% of patients with Parkinson disease will have difficulty swallowing.

Dysphagia is a problem because:

  • it can result in aspiration (food or fluid is going into the airway). Aspiration can result in pneumonia. Aspiration pneumonia is difficult to treat despite the use of antibiotics, unless the cause of aspiration is eliminated
  • it can cause dehydration and/or result in malnutrition which in turn results in weakness, a decrease in natural immunity, an increased risk of infection and less potential to return to a previous level of function
  • it can cause choking and occasionally death
  • it can often be associated with reduced quality of life as food and drink is such an important part of our life and social connections
  • it can prevent patients from taking medications

All of these things can also result in an increased length of time in hospital.


What is Fibreoptic Endoscopic Evaluation (FEES)?

A fibreoptic endoscopic evaluation (FEES) is performed using a flexible scope with a camera attached to the end.  The scope is passed through the patient’s nose and the larynx and surrounding structures are filmed and can be reviewed by a specialised team of speech-language therapists (SLTs). The team use this information to create a comprehensive care plan for patients suffering from dysphagia.


What are we trying to achieve?

Value: Better, Best, BrilliantThe speech-language therapy team wanted to improve the way we manage dysphagia by:

  • accurately identifying whether a person is aspirating in a timely manner
  • improving patient’s quality of care by recommending the least restrictive, safe diet in a timely manner
  • improving patient and family knowledge and understanding of the problem by offering all patients the opportunity to see what was happening during their FEES procedure. Many patients report this is a very valuable experience when coming to terms with a long term swallowing problem or understanding the aim of rehabilitation

FEES patient


What did we find?

Prior to a mobile FEES service being introduced, the only objective method of assessing a patient’s swallow was a video-fluoroscopic x-ray swallowing study (VFS) carried out in the radiology department.  There were many limitations to this service and consequently many of our most vulnerable patients missed out on assessment.

The benefit of a mobile instrumental swallow assessment service is that more patients receive care that was previously available to only more limited numbers of patients.

Providing an objective assessment at the bedside also helps our cognitively impaired patients, e.g. those with dementia, by keeping the patient in a more familiar environment.


What have we done?

The speech-language therapy team worked closely with Olympus, a medical equipment company, to secure loan equipment for a trial at North Shore Hospital.  They also worked with University of Auckland Masters students to complete an audit of stroke patients to show the benefits of a mobile FEES service.

The aims were to:

  • increase availability of objective assessment to vulnerable patients
  • reduce the wait for instrumental assessment of swallowing
  • reduce pneumonia rates in the stroke population
  • provide better functional swallowing outcomes/quality of life for patients
  • reduce length of stay for stroke patients with dysphagia

Did we make a difference?

Goal

Outcome

Increase availability of objective assessment

Increased assessment rates from 6.4% to 39.2%

Reduce the wait for instrumental assessment of swallowing

Reduced from an average of 10.5 days to 2.3 days; assessment often occurred on the same day as referral

Reduce pneumonia rates in the stroke population

Reduction in post-stroke pneumonia rates from 12% to 7%

Provide better functional swallowing outcomes / quality of life for patients

Instrumental assessment resulted in the patient's diet either being upgraded or staying the same 96.5% of the time.

Increase of 13.3% in the number of patients leaving hospital on standard diets

Reduce length of stay for stroke patients with dysphagia

Unfortunately, there was an increase length of stay.  However it is impossible to determine whether this was a direct result of the study given the many factors that can affect length of stay


Where to from here?

Following this successful trial, we now have a permanent mobile FEES service for both North Shore and Waitakere Hospitals.  The portability of the equipment means we can respond quickly with our instrumental assessment and see patients at their bedside regardless of their mobility and medical status.  This means FEES is now a crucial part of any dysphagia assessment in our Intensive Care Unit due to the very high rates of silent aspiration in patients in critical care.  We also offer FEES as an outpatient service to the benefit of our community.