Modified Mondays: When the ball gets dropped

This is a really difficult Modified Monday to share. Our patient this week doesn’t have anything really “interesting” to look at, but it’s still a good lesson. She was seen by our Pittsburgh team recently, with a history of a congenital condition that resulted in minimal ability to communicate expressively and receptively (We are not sharing the condition just to increase privacy). She had a PEG tube place over a year ago while in acute care with COVID, a family member reported that they did not believe she had an instrumental swallowing assessment but did recall that she was “pretty sick” at the time. No notes on any swallow study were in the patient records from that stay. From the hospital, she was discharged to a skilled nursing facility, where she was evaluated clinically. No instrumental was completed, and the patient remained NPO with the PEG. Over the course of the next few months, she did receive therapy (still with no instrumental) but was eventually discharged due to “lack of progress” without an instrumental, stating the “patient can’t follow commands for a study”. The family member requested some food be tried but was told that the patient would have to be changed to Hospice care (wrongly), since NPO was still the recommendation (still no instrumental). The patient eventually went back to the hospital with an infection and respiratory distress, at which time the family member decided to choose a different skilled nursing facility upon discharge. The SLP at the new facility, noting that they patient had no record of instrumental assessment, immediately sent in the referral to us for the MBS study.

Our Pittsburgh SLP Natalie immediately found… a perfectly functional swallow. The patient is edentulous, so she takes a little extra time to masticate, but other than that… WNL. Clearly, we don’t know when this patient would have been fine for PO… but since an instrumental imaging study was never completed, we don’t know if the patient was ever demonstrating an impaired swallow at all. Or needed a PEG. Or needed therapy.

The other part of this story is that there were multiple notes from the hospital and the other SNF that the patient “tried to sneak food”, was “caught trying to sip from the sink in her room”, and the family member “kept asking to feed the patient”. Not to mention the weight loss, lack of progress in improved medical status, with physical therapy, the infections, and poor “cooperation with rehab”.

As SLPs, we ARE the point person to make sure the swallow ball doesn’t get dropped. We just cannot “assume” someone else will catch it, or allow it to happen. This patient could potentially have had significantly improved outcomes, both with regard to medical status and quality of life. Fortunately she is now enjoying eating and drinking, the PEG is scheduled for removal, the family member is relieved and thankful…but all of this happened probably much, much later than it should have, and a great expense to the patient, not to mention the healthcare system.

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