Implementation of Esophageal Screening in an Outpatient Hospital-Based Setting: A Quality Improvement Project

Abstract

Purpose: Despite evidence supporting interconnectivity of oropharyngeal and esophageal swallowing, evaluation and treatment are dichotomized. When the videofluoroscopic swallowing study (VFSS) only considers oropharyngeal swallowing, the full scope of swallowing impairment may be missed. A lower rate of esophageal screening in an outpatient hospital setting may result from lack of speech-language pathologist (SLP) training and understanding of screening feasibility. This project was an internal quality improvement project (QIP) at Mayo Clinic in Arizona to (a) educate and train SLPs on conducting the Robust Esophageal Screening Test (REST) and (b) determine the feasibility of REST protocol implementation in a multidisciplinary swallow clinic. Method: Fishbone analysis was used to identify potential causes of the gap in quality. Six Sigma methodology was used to outline the QIP. SLPs were trained in the REST protocol. To ensure adequate training, reliability ratings were assessed with the Cohen's kappa statistic. Esophageal screening via REST was implemented as an adjunct to the standard protocol during VFSS over a 3-month period for referred patients with dysphagia. Clinical findings were recorded. Results: All clinical rater SLPs reached the threshold of κ = .8 to ensure adequate rater reliability. Among 136 outpatients who underwent esophageal screening via REST, 100 patients completed the full REST screening and 36 completed a partial REST screening. Of the 100 full screenings, 80 patients had a failed screening, which indicated a potential esophageal swallowing impairment. Findings were discussed by members of the multidisciplinary dysphagia care team. Conclusions: The results of this QIP show that focusing on assessment of dysfunction and interplay across the swallowing continuum can substantially improve patient care by expediting and specifying next steps of the multidisciplinary dysphagia care team.