Thanks to Krystina Crolla-Barker for this blogpost, that she based on conversations and contributions for many of the delegates who joined us for this event on 2nd July 2019.
I am writing several months on from the thought-provoking conference held in July this year in relation to “Using thickener in the management of dysphagia: the disconnection between evidence and practice” presented by Tracy Lazenby-Paterson.
The audience was broad and largely dominated by Speech and Language therapists, with a specialist interest in pursuing improved knowledge in the management in Dysphagia practice.
As thickener continues to be the most widely employed and accepted intervention used by Speech and Language Therapists in the management of Dysphagia, we need to be asking ourselves as practitioners ‘what is the clinical rationale for this recommendation?’ ‘Can we justify its use clinically to the patient?’
On reflection the themes identified from the day were focused on the familiar prevalent assumptions in clinical practice for why we use thickener:
“It reduces the risk of aspiration”
“It slows down the oral transit time and therefore improves swallowing function”
On review of the evidence presented in the session today; it appears that thickener doesn’t actually stop aspiration (Logemann et al, 2008) and stopping or reducing aspiration does not improve real-life clinical outcomes (O’Keefe, 2018). The challenge is that the use of thickener in clinical practice is widely contradicted by clinical evidence; and therefore if we are using evidence-based practice principles, the question ought to be ‘should we still use thickener in the management of dysphagia knowing the evidence and the clinical risks it poses?’
Challenges to our current clinical practice (comments from workshop participants):
“Without data (or evidence), you’re just another person with an opinion. The ADP day challenged views and opinions about the use of thickening fluids with a wealth of evidence base all collated and summarised to underpin discussion. A great space to review and reflect on current practice”
“We welcome that research is leading us to want a more accurate diagnosis of aspiration pneumonias.”
“It’s good to remember all the strategies we have to manage the risks identified by Langmore (use the NPSA 2007 documents) and have less reliance on thickener alone.”
“This day has challenged the very core of what we often recommend, and rightly so. Our patients will greatly benefit from its implications and although we have a journey to get to not using thickener it is one I am excited to start.”
Barriers to change (comments from workshop participants):
“We’ve always done it this way”.
Throughout the day there were practitioners who appeared reluctant to change their way of clinical practice despite the overwhelming evidence to suggest that this should not be the primary tool used within the toolkit of interventions in Dysphagia management. The main concern raised was “well if I don’t use thickener, then what else should I do”; of which on reflection the answer is logical, we use all of the other tools in the toolkit first for example positioning, oral care, compensatory strategies, sensory modification – we go back to all the interventions we learnt as part of our Dysphagia training and start to consider these the primary interventions.
And finally the question asked about “they are still getting chest infections – what now?” is answered on a person-specific level, however it’s worth thinking constantly about whether you have done all you can and there is nothing else to recommend rather than recommending a knowingly harmful intervention.
And the feeling of not being able to do anymore goes against our principles of being a good clinical practitioner, but accepting that this is what is necessary in good clinical care may take some time.
In summary, I have taken away that I need to review the evidence-based practice of interventions that I recommend and be more transparent with patients if I am recommending a intervention that comes with associated risks; and then supporting decision-making using a person-centred approach. And in addition, change takes time and some people will always be resistant; but we should be referring back to ‘what is the clinical rationale for my intervention’ all the time to support us in our clinical roles.