NHD clinical - HEF watch
Emma Jarvis is a Clinical Specialist Speech & Language Therapist
by Emma Jarvis in the Lewisham Home Enteral Nutrition Team and at Kings College
Registered Speech & Language Therapist,
Hospital. Her main interests include dysphagia assessment and
Kings College Hospital
rehabilitation and palliative care.
Dysphagia rehabilitation
Joint working with dietitians resulting in feeding tube removal with non-oncology patients
The Lambeth, Southwark and Lewisham Home Enteral Nutrition (HEN) Team is a specialist community service based in Camberwell,
South East London. The team has 1.6 WTE speech and language therapists (SLTs) and approximately 90 patients on the adult caseload
needing SLT input with dysphagia.
The recent development of a local community head and neck can- medication (e.g. insulin) as the feeding regime changes.
cer team means that only three percent of the caseload now has an Retrospective data has been collected for 2006 and 2007 to
oncology diagnosis. Therefore the focus of this article is on those show the number of feeding tubes removed as a result of SLT and
patients with a non-oncology diagnosis, e.g. neurological and surgi- RD joint working. Data for 2008 and 2009 is collected and due anal-
cal who make up the majority of the caseload. ysis in 2010. The figures are for non-oncology patients and include
The role of the SLT in this team is to assess and manage dys- all tubes except nasogastric. The reason why NGT patients were
phagia whilst communication impairments are addressed by com- excluded is because this type of tube is usually chosen as a tem-
munity colleagues. Patients can be divided into four main streams porary feeding measure, up to four weeks (2) with the expectation
depending on the SLT input they receive: being that it will not be required long term.
• Those patients who are slowly deteriorating or palliative.
• Those patients who are stable but with no potential to improve.
Number of Number of
• Those patients whose oral intake may be slowly increased over
Diagnosis patients patients
time and the balance of oral nutrition support and tube feeding
in 2006 in 2007
reviewed.
• Those patients with specific rehabilitation goals and potential to
CVA 11 7
make good progress. Brain Injury 3 1
Nerve damage
My ultimate aim with the latter two groups is to rehabilitate dys-
via trauma/ 3 2
phagia, work in partnership with the dietitians, increase patient’s
surgery
oral intake, reduce their dependence on the feeding tube and to
remove the feeding tube whenever possible.
Dementia 1 0
In order to assess disordered physiology, a videofluoroscopy (VF) Other 2 5
is the instrumental assessment of choice. Approximately 40 per cent
Total 20 15
of patients have a videofluoroscopy, either having had one as an
inpatient or ordered specifically once the patient is home. Dysphagia
Table 1 – Numbers of feeding tubes removed
therapy is then offered. It can be intensive, twice daily everyday for
one week (1), weekly or monthly (following a home programme) de-
It is important to highlight the number of patients who make
pending on resources, patient motivation and patient need. Therapy
substantial improvements with their swallowing but not to the
involves the SLT performing exercises with the patient targeting spe-
point of tube removal. The use of a diet scale is starting to be
cific impairments found on videofluoroscopy. Oral intake is always
trialled in order to collect data to demonstrate this. Older pa-
encouraged even if only safe to do so in very small amounts. There
tients and those with tubes in situ for more than 12 months
are a few exceptions where the risk is too great. Compensatory
predominantly had a neurological diagnosis. This shows that
strategies are introduced to make swallowing a bolus during therapy
chronic dysphagia in both young adult and elderly populations
as safe as possible and to prevent aspiration.
can be rehabilitated in the community.
Evidence exists to show head and neck cancer outcomes
Joint working with the dietitian is essential to keep reviewing the
with tube removal, but this data highlights that patients with
balance of oral nutrition/hydration and tube feeding. Experience has
neurological diagnoses also have good potential to achieve
shown that some patients become dependant on tube feeding quickly
tube removal particularly with effective joint working between
and need encouragement and advice from both disciplines to move
SLT and dietitians.
back onto oral intake. Common factors which need addressing are
ensuring the patient has enough of an appetite to eat, flexibility with References
pump versus bolus feeding as amounts decrease, the introduction of
1 Huckabee ML & Cannito MP. Dysphagia Spring, 1999, 14 (2): 93-109
2 NICE Nutrition support in adults: Oral Supplements, Enteral Tube Feeding and Parenteral
oral supplements to top up oral intake if appropriate and reviewing Nutrition. NICE August 2006. Available at: www.nice.org.uk
Need to recruit a dietitian?
call 0845 450 2125 (local call rate) www.dieteticJOBS.co.uk
24 NHDmag.com Mar '10 - issue 52
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