Can human mannequin-based simulation provide a feasible and clinically acceptable method for training tracheostomy management skills for speech-language pathologists?

PURPOSE: Workplace training for tracheostomy management is currently recognized to be inconsistent and insufficient. A novel approach, using technology-enhanced simulation, may provide a solution to training tracheostomy management skills by providing a consistent, time-efficient, and risk-free learning environment. The current research evaluated clinicians' tracheostomy skills acquisition after training in a simulated learning environment and explored changes in clinicians' confidence and perceptions after the experience. METHOD: Forty-two clinicians with no or low levels of tracheostomy skill attended one of six, 1-day simulation courses. The training involved both part-task skill learning and immersive simulated scenarios. To evaluate clinicians' acquisition of manual skills, performance of core tasks during the scenarios was assessed by independent observers. Questionnaires were used to examine perceived outcomes, benefits, and perceptions of the learning environment at pre-, post-, and 4 months post-training. RESULTS: Only 1 clinician failed to successfully execute all core practical tasks. Clinicians' confidence increased significantly ( p < .05) from pre- to post-workshop and was maintained to 4 months post-workshop across most parameters. All clinicians reported positive perceptions regarding their learning outcomes and learning in a simulated environment. CONCLUSION: These findings validate the use of simulation as a clinical training medium and support its future use in tracheostomy competency-training pathways.

Validation of predictive factors of dysphagia risk following thermal burns: a prospective cohort study.

PURPOSE: The objective of this study was to prospectively evaluate the validity and reliability of a risk factor model developed for use in predicting dysphagia risk within the first 24 h after injury/hospitalisation in patients with thermal burns. METHOD(S): Three hundred and fifty six patients with thermal burns, with or without inhalation injury, who were consecutively admitted to and received management at a quaternary state-wide burn center over a 12 month period, were included. Patients were reviewed for dysphagia risk by nursing staff using an established set of predictive factors. If risk factors for dysphagia were present, referral to speech-language pathology was initiated to investigate swallow function. RESULT(S): Of the 356 admissions, 83 patients were identified as meeting one or more risk criteria for dysphagia after burn. Of these, 24.9% (n = 30; 8.42% of the total cohort) presented with dysphagia. Using these criteria, sensitivity and specificity for detection of dysphagia risk were high (100% and 83.74%, respectively). The criteria over identify patients who may be at risk of dysphagia and who require dysphagia assessment (positive predictive value = 36.14%). However, as a set of predictors of dysphagia risk when thermal burn is the only complaint, a negative result reassures that a patient does not have dysphagia (negative predictive value = 100%). CONCLUSION: Overall, the risk factor model provided a valid measure for predicting dysphagia risk. Incorporating these criteria into a dysphagia screening assessment can ensure an evidence-based pathway for early detection and timely referral to speech-language pathology for patients at risk of dysphagia after thermal burns.

Clinical progression and outcome of dysphagia following thermal burn injury: a prospective cohort study.

The objectives of this study were 1) to establish clinical profiles of dysphagic and nondysphagic individuals following thermal burn injury and 2) to provide a clinical profile of the progression and outcome of dysphagia resolution by hospital discharge for a dysphagic cohort. A total of 438 consecutively admitted patients with thermal burns were included. All patients underwent a clinical swallowing examination. Medical parameters regarding burn presentation and its treatment and speech-language pathology specific variables from admission to discharge were collected for each participant. Dysphagia was identified in 49 patients via clinical assessment, and their course of recovery was followed up until the point of dysphagia resolution or discharge. No significant difference was observed between the dysphagic and nondysphagic groups in age, gender, and injury etiology. However, the dysphagic cohort was significantly different from the nondysphagic group in all variables pertaining to injury presentation and medical management. Individuals with dysphagia took significantly longer to start, and maintain, oral intake and required nonoral supplementation for three and a half times longer than those who were nondysphagic. Length of speech-language pathology intervention averaged 1 month for the dysphagics and increased with dysphagia severity. Return to normal fluid consistencies occurred in >75% of dysphagic individuals by week 7 after injury, although resumption of normal diet textures was more protracted, with 75% resuming normal oral intake by week 9. Dysphagia had resolved in 50% of the cohort by week 6, and by hospital discharge, 85% of the dysphagic individuals had resumed normal oral intake of thin fluids and a general diet. This is the first large prospective cohort study to establish clinical profiles of dysphagic and nondysphagic cohorts and document the nature of dysphagia and patterns of recovery within the thermal burn population. These current data will assist the allocation and planning of speech-language pathology services and provide baseline data on the course of dysphagia resolution in the adult thermal burn population.

Physiological characteristics of dysphagia following thermal burn injury.

The study aim was to document the acute physiological characteristics of swallowing impairment following thermal burn injury. A series of 19 participants admitted to a specialised burn centre with thermal burn injury were identified with suspected aspiration risk by a clinical swallow examination (CSE) conducted by a speech-language pathologist and referred to the study. Once medically stable, each then underwent more detailed assessment using both a CSE and fiberoptic evaluation of swallowing (FEES). FEES confirmed six individuals (32%) had no aspiration risk and were excluded from further analyses. Of the remaining 13, CSE confirmed that two had specific oral-phase deficits due to orofacial scarring and contractures, and all 13 had generalised oromotor weakness. FEES revealed numerous pharyngeal-phase deficits, with the major findings evident in greater than 50% being impaired secretion management, laryngotracheal edema, delayed swallow initiation, impaired sensation, inadequate movement of structures within the hypopharynx and larynx, and diffuse pharyngeal residue. Penetration and/or aspiration occurred in 83% (n = 10/12) of thin fluids trials, with a lack of response to the penetration/aspiration noted in 50% (n = 6/12 penetration aspiration events) of the cases. Most events occurred post swallow. Findings support the fact that individuals with dysphagia post thermal burn present with multiple risk factors for aspiration that appear predominantly related to generalised weakness and inefficiency and further impacted by edema and sensory impairments. Generalised oromotor weakness and orofacial contractures (when present) impact oral-stage swallow function. This study has identified a range of factors that may contribute to both oral- and pharyngeal-stage dysfunction in this clinical population and has highlighted the importance of using a combination of clinical and instrumental assessments to fully understand the influence of burn injury on oral intake and swallowing.

Incidence and predictive factors for dysphagia after thermal burn injury: a prospective cohort study.

The objective of this study is to determine dysphagia incidence for a consecutively admitted population of thermal burn injury patients and to determine admitting characteristics that can be used to reliably predict patients at risk of developing dysphagia after thermal burn. Four hundred thirty-eight patients with thermal burns, with or without inhalation injury, who were consecutively admitted to and received management at a state-wide burn center over a 2-year period (2007-2009) were included. All patients meeting the project's inclusion criteria underwent clinical swallowing assessment to determine the presence or absence of dysphagia. Dysphagia incidence was found to be 11.18% (n = 49) in the admitted population. Dysphagia severity at initial assessment was classified as severe for 40.82%, moderate for 30.61%, and mild for 28.57%. Statistical analysis revealed a core set of statistically significant parameters known within the first 24 hours postinjury that showed strong sensitivity and specificity for detection of dysphagia risk. These include, in isolation or in combination, with the consideration of increasing age, TBSA burnt ≥18%, head and neck burns, need for escharotomy, inhalation injury, need for intensive care admission, and need for mechanical ventilation. This is the first large, prospective cohort study to document dysphagia incidence within the thermal burn population and to validate key predictors for dysphagia risk in this population. These data will assist the allocation and planning of speech pathology services and provide an evidence-based pathway for ensuring early identification and management of patients at high risk of dysphagia after thermal burn injury.

The challenges of dysphagia management and rehabilitation after extensive thermal burn injury: a complex case.

The role of the speech pathologist in the burns population is still emerging, with detailed discussion of the assessment and management of dysphagia limited to date. This report describes the case of a 60-year-old man who developed severe contractures of the head and neck and oropharyngeal dysphagia after sustaining 53.5% deep partial- and full-thickness burns. Although some aspects of rehabilitation were confounded by a preexisting mild intellectual disability, the patient was able to participate in an intensive regimen of active and passive exercise to rehabilitate his oropharyngeal dysphagia. Significant oral contractures remained; however, the patient was discharged without tracheostomy and consuming a texture-modified diet with no signs of aspiration. To our knowledge, this is one of a small handful of reports that document speech pathology management of the burns population, and a first that identifies and outlines specific characteristics of, and rehabilitation strategies for, dysphagia in a burned individual.