Bedside FEES assessments:

The Royal College of Speech and Language Therapists recommends that Fibreoptic Endoscopic Evaluation of Swallowing (FEES) should be performed as part of a multidisciplinary team (MDT) approach to dysphagia management. However, individuals receiving neurorehabilitation outside of an acute hospital setting face multiple challenges accessing FEES and their rehabilitation programmes often do not benefit from the insight regular FEES assessments bring.

In order to create equity of access for residents, The Dean Neurological Centre in Gloucestershire, part of Elysium Neurological, have invested in the Ambu single use endoscopy system.

In this EveryExpert article we speak with Gerry Roxburgh, a specialist neurological Speech and Language Therapist (SLT) with over 20 years’ experience in neurorehabilitation in both post-acute and residential settings, and who is currently the Speech and Language Therapist at The Dean.

Gerry explains how having onsite access to FEES is already yielding significant benefits for residents at The Dean, including resident Molly who was enabled to move from ‘Nil by Mouth’ to a pureed food diet because of the insight provided by FEES.

What is a Fibreoptic Endoscopic Evaluation of Swallowing? 

Fibreoptic Endoscopic Evaluation of Swallowing (FEES) is an objective swallowing assessment using a long thin camera called an endoscope which is inserted through the nose.

The assessment provides a detailed view of the throat anatomy and allows SLTs to directly visualise key swallowing functions, secretions and sensory responses. The safety and efficiency of the swallow can be viewed in real-time whilst eating and drinking different textures and thicknesses, and also in the absence of food and liquids.

There are multiple benefits for both the clinician and patient.

FEES enables SLTs to conduct an in-depth assessment of dysphagia (difficulty or discomfort in swallowing) with accuracy far beyond any subjective reviews.

It can also be used to detect aspiration, (when something you swallow enters your airway (trachea or windpipe) or lungs), even when the aspiration is silent and could be missed in a subjective review. 

FEES is portable so can be conducted at the bedside, or wherever the patient is most comfortable. This also means that it can be repeated more regularly, resulting in more frequent patient assessments which enables more effective dysphagia management.

FEES also provides a direct view of throat anatomy, for example the larynx and upper airways so it can provide important information for the wider multidisciplinary team (MDT) for example in  tracheostomy care.

Best practice for dysphagia management

The Royal College of Speech and Language Therapists states within their position paper entitled, Fibreoptic Endoscopic evaluation of Swallowing (FEES): The role of speech and language therapy. (2020) that FEES “should be performed as part of a MDT approach to dysphagia management” (2020:6) however, “there remains inequity of access for patients between settings and clinical groups, and between and within individual healthcare trusts.” (2020:8) 

In practice this inequity translates as limited patient access to FEES within acute hospital settings, typically with long waiting lists and lengthy referral procedures.

For outpatients, such as those being treated within a private setting, the wait time is increased and patient outcomes are impacted because MDTs do not have the most accurate and frequent assessment information to inform therapy.

To rectify this issue and improve dysphasia assessment and management, the MDT at The Dean Neurological Centre in Gloucestershire now have access to an onsite FEES bedside assessment that can be used by a trained SLT when appropriate for the resident.

The availability of FEES onsite removes the challenges experienced when trying to access the assessment in an acute hospital setting, improving resident experience and outcomes.

Gerry Roxburgh, Speech and Language Therapist at The Dean, explains the FEES system currently being used and the immense benefits for residents. 

“The benefit is enormous from a patient experience perspective. By conducting the procedure onsite we can make the experience as positive as possible in a familiar setting, with a team that residents know.

"We are able to use real food that is meaningful to them, ensure their position is optimised in their own seating or bed and give the individual the time that they need to process the complex information that goes along with such an assessment.

"We encourage them to have a relative present to support them if they wish and avoid all of the distress and fatigue that can be caused by travelling to and from the local hospital for assessment.

“The majority of residents have swallowing difficulties as a result of chronic neurological conditions such as head trauma or progressive illness and it often takes a considerable length of time for that person to be ready to travel to hospital.

"Add to that time the actual transport and navigating the hospital experience, it’s a big effort for them, the fatigue and the stress that that induces is quite significant. 

“Here at the Dean Neurological Centre we have recently invested in a disposable system. This is the most appropriate system for the frequency of assessments we need to conduct.

"A permanent system involves more complicated sterilisation of the endoscope both before the assessment and immediately afterwards. So a disposable system is more cost effective for us in the short term, and also in the long term because we can upgrade our system more easily.”

Continuity of person-centred care

There’s also a significant benefit in the continuity of care that can be provided. If the assessment is delivered in an external service, the individual will not know the person assessing them, whereas now FEES at The Dean can be delivered by a familiar therapy team, in a comfortable environment at an appropriate pace, tailored to each individual.

Gerry continues: “FEES can now be a real-time assessment with food that is ‘real’ for the person being assessed – it can be something that they've chosen, or the family have prepared and brought it in. This makes it much more meaningful for them, plus the assessment can be completed in the most comfortable eating and drinking position for that person.

"Traditionally we might say someone should sit in a chair for FEES, but that may not be the best place for the person, sitting in bed might be more appropriate. In addition the time-frame to deliver the assessment is determined by the individual and we do not have time constraints.

"If required I can assess the person over the course of a meal and also observe the person in the period after food has been consumed. The process is now much more flexible and tailored to individual need.

“With such personalised assessments and care, our wish is that we will improve the choice and the variety of foods that our residents can safely eat and drink. We are able to tailor our active therapy programmes to support individuals to regain functional eating and drinking skills with objective information, building programmes that are meaningful and maximise safety.

"The more choice we are able to offer, the more eating and drinking becomes an enjoyable experience again. This all contributes to a better quality of life for our residents and their families as they ideally regain the social benefits of eating and drinking a varied diet in varied locations.”

From Nil by Mouth to a pureed diet

The first resident at The Dean to benefit from the new FEES bedside assessment was a 24-yr-old woman called Molly who has locked-in syndrome, caused by a spontaneous brain haemorrhage.

When Molly arrived at The Dean in late 2023, she was nil by mouth, apart from 5 tsps. of yoghurt per day for taste stimulation. Gerry Roxburgh explains how Molly was assessed using a bedside FEES assessment and the impact that it has on her daily life.

Gerry says: “Molly was the first resident to be assessed using FEES and the results have been very positive for her. During bedside assessment she was showing signs of aspiration when she swallowed, and traditionally this would’ve meant that we would pull back from swallow management for safety concerns.

“However because of the increased visibility provided through the FEES, I was able to see that she was effectively clearing her throat during the swallow and it did not impact her breathing. It was possible to identify what was challenging for Molly during her swallow and to determine how we could support her to make it safer.

"As Molly was able to clear her pharynx well, the evidence demonstrated that it was right to move her forwards into the next phase of her rehabilitation. 

“With the FEES I can see what's happening and how it's happening. I know what I have to do to support her to take the next stages to improve and help her develop her swallow, but it is always a balance to get right.

"You can't learn to swallow without swallowing, just like you can't learn how to catch a ball, without catching a ball. But it has to be done in a safe and supported way. The clarity provided by FEES means that we know that we are keeping Molly safe.

“Since the assessment Molly’s been able to eat pureed food and so now she can have whatever she fancies - curry, Bolognese, chocolate pudding. She has a real variety now, and this has also had a positive impact on her wellbeing from a social perspective. For example, she has been able to go out on visits with her mum to a pub or a café and also with friends.

"When someone is nil by mouth it takes away more than just food, you’re taking away the basic routine of three meals a day, their daily structure, along with the social element and the enjoyment. But with FEES we can offer residents, where appropriate, the chance for a safe graduated programme of dysphagia management.

"FEES offers reassurance for the resident and their family, they can be more confident in our recommendations and what actually is possible for them. They can also see their progress and are encouraged to continue and achieve more rehab goals.”

In conversation with Gerry, Molly was able to provide the following answers to the below questions via eye gaze technology.

Q: How did you feel when you were told that you could eat pureed food? 

Molly: I felt happy when I could have a better variety of food.

Q: What did your first food taste like?

Molly: “Yoghurt – it still tastes like yoghurt!  Chocolate has been my favourite food to start eating again.” 

Q: What’s been your favourite drink to taste again?

Molly: “I really enjoyed a lager at the pub with mum.”

Q: Is there anything you haven’t tasted that you are looking forward to? 

Molly: “I really want to eat a burger.”

Q: How did you find the FEES assessment process?  

Molly: “The FEES assessment was a little uncomfortable. I would have liked to be able to continue eating more food at different textures.”

Q: How do you feel about the support from the team at The Dean? 

Molly: “I feel happy with the support regarding eating and drinking. I am really enjoying my food and take it one day at a time.”

Molly’s mum also commented that the FEES provided vital insight that enables Molly to take informed risks and enhance her quality of life.

“We can make sensible decisions regarding Molly’s eating and drinking. We know the risks and we can balance these with the pleasure that we have as a family doing social things.”

Empowering decision making

FEES brings unparalleled visibility and clarity to dysphasia management in real-time. For Gerry this has improved her decision making and she has increased confidence in her work.

Gerry says: “Working with bedside FEES assessment is very empowering for a SLT because you are able to see what is happening in real-time. It’s not subjective, it isn’t just me saying ‘I assume this is happening.’ The results are definitive because you can see what is happening and therefore we have the power as SLTs to then provide treatment and rehab assertively.

"We are enabled to actually rehab the swallow, which can bring huge benefit for the individuals we are working with. Then, in situations where assertive rehabilitation is not possible due to the inherent risks of aspiration, we can see this clearly and we can be confident in our decision making and that it is the correct approach to take for the individual.

“The other huge benefit both for clinicians and residents here at The Dean, is that they don’t have to wait for assessments and we can conduct them at the appropriate time for the individual.

"Not having to wait six months or longer means that we have the confidence to be able to treat as the person needs, when they need it. This again gives you the ability to be more assertive in your management. 

“We can treat it in a way that is safe, but we can be confident in our positive risk taking which is important in retraining swallow. You can't retrain swallowing without food, not properly, but that comes with an element of risk which is individual to each person.

"But with bedside FEES assessment we can be confident that our positive risk taking is as safe as it can be. This provides real clarity, and also the confidence to proceed or not, and make the most appropriate decision for the individual you are working with.”

Get the latest insights, blogs and news from Elysium Neurological over on their EveryExpert thought leadership hub: elysiumhealthcare.co.uk/neurological/every-expert/

References:

Wallace S, McLaughlin C, Clayton J, Coffey M, Ellis J, Haag R, Howard A, Marks H, Zorko R. Fibreoptic Endoscopic evaluation of Swallowing (FEES): The role of speech and language therapy. London: Royal College of Speech and Language Therapists, Position paper. 2020