Season 3 Episode 1 – DYSPHAGIA & COVID-19: IMPACT ON PRACTICE

00:00:13 ➝ 00:03:30 B. Hopkins: Hello and welcome to Clinical Nutrition Notes – a podcast where we speak with guest experts and opinion leaders about the art and science of clinical nutrition – brought to you by Nestlé Health Science Canada. This podcast is intended for healthcare professionals, for education purposes.

I am your host today, Bethany Hopkins, Medical Affairs Manager with Nestlé Health Science.

Today we’ll be talking with 3 clinicians across the country about how COVID-19 has had an impact on their dysphagia practice, key learnings and implications for the future.

I’ll take a minute now to introduce our 3 panelists.

Peter Lam is a registered dietitian and credentialed food service executive in Vancouver, British Columbia. Over the past 25 years, he has focused his practice in dysphagia and meal-time management. Peter provides consultation to the healthcare, food service and hospitality industries and is currently co-chair of the International Dysphagia Diet Standardization Initiative.

Jean Helps is a registered dietitian and regional clinical nutrition manager for long- term care within the Winnipeg Region Health Authority in Manitoba. Jean is registered with the College of Dietitians of Manitoba. In her role within the Winnipeg Region Health Authority, Jean provides support to clinical dietitians and sites within the region. Considering the prevalence of dysphagia in long-term care, Jean has a special interest in this setting. By working with experts and frontline dietitians, she’s developed practice guidelines for dysphagia management and has also been involved in tailoring practice considering the impact of COVID-19 in challenging us in continuing to provide high quality care in a difficult environment.

Now moving further East, Ellen Andrews is an adult medical speech language pathologist with Bruyère Continuing Care in Ottawa, Ontario. Over the past 19 years, she has served patients with complex and chronic health conditions including dysphagia, augmentative and alternative communication and respiratory care. Ellen is an enthusiastic supporter of the International Dysphagia Diet Standardization Initiative (IDDSI), and served as leader of implementation at IDDSI across her multi-center site in 2017. During COVID-19, Ellen has put on her mask and her headband, changed her wardrobe to scrubs, so she’s been able to continue doing her work at St. Vincent Hospital.

A warm welcome to all 3 of you and thank you for joining us today. As we know COVID-19 has had a considerable impact on the lives of individuals and has touched virtually all areas of healthcare. When we’re thinking about the field of nutrition, one of the areas that has been particularly affected has been the area of dysphagia assessment and management. Today we’ll be talking about the implications of the COVID-19 pandemic and really getting each of your perspectives on how this has changed your dysphagia practices.

So Peter, let’s begin with you on the West coast. You’re involved in dysphagia in the primary care setting. Can you briefly share the impact of COVID-19 on your dysphagia practice.

00:03:33 ➝ 00:05:55 P. Lam: Thanks Bethany. COVID-19 has had a huge impact on how we perform dysphagia assessments in many different settings. One of the primary things that I do, is to work with my speech pathology or occupational therapy colleague, to perform dysphagia assessments in a home care setting, and unfortunately with COVID-19 there are many people who are no longer wanting us to come and visit them in their home. So many of our assessments are now having to be done virtually. The challenges have just been immense. First of all, with the clientele that we support, half of them, the challenge is really learning the technology, even just to get an assessment setup in a virtual environment. We need to take the extra time to actually teach them how to use the technology before we can even get into the assessment itself. Furthermore, the actual instructions to have people perform any type of oral mechanism, or oral motor exam, is not really done as easily, because you’re not there physically, demonstrating this. Some of our clients who have visual impairment. They have challenges seeing what’s happening on the screen. I know this sounds really weird when I say this, but one of the things I miss most is the ability to have the sense of smell. In a virtual environment, you might be able to see. You might be able to hear, but you certainly can’t smell. You don’t know what the food smells like. You don’t know what the environment smells like. This may sound again, very weird, but you don’t even know what the person’s breath smells like, and that could tell you a lot about the person’s oral hygiene. That’s really just a little bit of how it’s impacted our practice in a home care environment for dysphagia management.

00:05:56 ➝ 00:06:42 B. Hopkins: Yes, thank you Peter. It’s interesting. I can see everyone’s heads nodding as you’re speaking. But, eating is such a tactile experience, and involves so many senses. Just imagining the challenges and not to mention the fact that, you know, we’re not all IT experts. So getting used to the technology and the individual we’re working with, getting them used to the technology is really quite something that many of us have never faced before.

Thank you for sharing that.

Jean I’ll turn over to you now. What are you seeing from your perspective as a clinical nutrition manager, and how has COVID-19 had an impact on dysphagia management in long term care?

00:06:44 ➝ 00:08:05 J. Helps: Thank you Bethany. COVID-19 has inherently affected some aspects of our practice. In long-term care, we need to protect frail, older adults, with multiple co-morbidities. So early on in the pandemic, what that meant was a change from communal to physically distanced dining. This has affected our ability to assess and monitor. And I think Peter of some of our discussions of how being in the dining room and seeing how people are doing is really important. Peter, you had commented on some of the challenges that you have, in having individuals demonstrate their ability to do certain things, and while it is a different kind of challenge, the challenge still exists in our setting, and that is wearing PPE definitely limits our ability to demonstrate for our clients. The last thing I want to mention is dietitians have been involved in pandemic menu planning, and from a dysphagia perspective, this has resulted in fewer texture modified diets available, in the interest of easy to prepare meals for less staff. And this is another unfortunate consequence of the pandemic, in that, there are fewer food choices for residents.

00:08:06 ➝ 00:09:02 B. Hopkins: It’s interesting Jean to hear the parallels between your experience in long term care and Peter’s experience in the community, and again coming back to the value of meal-time observation. Even though people are there in person, it’s not the same, what we do to observe and people being physically isolated and just some of the efficiencies, or inefficiencies that potentially creates and then the impact it has on the actual food being served as well in variety. There’s lots of spinoffs related to this in the long-term care setting.

Now Ellen, interested in your perspective, working in a facility environment as well, but in your case a chronic care environment. What has been the impact of COVID-19 in your setting?

00:09:03 ➝ 00:11:46 E. Andrews: I’ve really found COVID-19 has been a series of evolving stories. When this went all the way back to March, our practice initially was very little impacted. We lost access to out-patient assessment services. Our video fluoroscopies were contracted to another healthcare facility. But otherwise, we were really functioning almost as normal, which was strange in other ways, being the only one of my family, and the only one of most of my acquaintances who was still getting up, getting dressed, and going out the door every morning. Certainly as the spring and summer evolved we dealt with a series of very upsetting outbreaks in our long term care facilities where we had voluntary deployment of many therapy staff to go help out with very basic tasks of patient care/resident care, to get through that. Unfortunately, the second wave has had an absolute, major and quite devastating affect on my organization. As I speak, we have just come off of a facility-wide outbreak that was focused on our respiratory care program and we still have units in our hospital that remain on outbreak. This had immediate changes in our clinical practice. Staff was immediately cohorted to certain areas and was no longer allowed to travel even between units. So, many challenges of coordinating services in that regard. As we know COVID being so contagious, we had many, many staff sent home either with COVID or just on isolation precautions when that outbreak hit, and so we immediately went into a severe issue of staffing collapse. My role as a speech language pathologist has changed radically in the last 2 months. I’ve been very well employed doing other jobs. I’ve been a porter, I’ve been a feeder. I’ve stocked linen carts. I’ve used my passion for communication to facilitate Facetime conversations with families. And I’ve really been called upon as a member of an interdisciplinary team to facilitate my colleagues who are either absent or restricted from certain units because of the infection risk. So I have helped the social worker fill out forms. I’ve dispensed booties for the OT. I have done clinical assessments with a registered dietitian over Facetime. I’ve consulted with speech pathologists in other facilities by telephone and by email to try and continue to offer our patients the services that they need. As we’ve looked at our dysphagia practice, we’ve had to limit non-urgent issues and this has certainly led to delays in addressing, maybe less urgent issues, but very, very important for our patients relating to things like quality of life.

00:11:47 ➝ 00:12:48 B. Hopkins: I mean, we can see you today, joining our call in your scrubs Ellen, giving us a real sense of what’s happening. The whole concept of interdisciplinary collaboration, and cross-training, it’s really taking that to a whole new level that some of us, wouldn’t have imagined a year ago, so thank you very much for sharing that.

When we’re thinking about the future, you know, we don’t have a crystal ball and that’s probably a good thing. Although thinking about the future, I just want to take a moment to think about what each of you anticipates for the future, knowing what you know now, the implications of a COVID-19 pandemic, and how this might shape your dysphagia practice moving forward. So Jean, let’s start with you this time. What do you envision at this point for the future of dysphagia in long term care given the pandemic and the learnings.

00:12:49 ➝ 00:14:50 J. Helps: In my region, COVID cases are on the rise and as a result, the plans that we have developed in the spring are being reinforced. From a clinical perspective, what this means is coordinating our visits on the unit, so we don’t spend a lot of time going to and between units. We also need to pair with complimentary disciplines and so, Ellen, speech language pathology is a key team member that we work with, and it was interesting to see that you have been doing that with dietitians in your area. We also have provided virtual service. Dietitians are deemed essential and are excluded from the one site model. However, we have provided virtual service which has meant a need to have really good communication with the unit. There is also the potential for staff shortages. All disciplines, including dietitians, need to perform at our full scope of practice, and this may mean that we’re doing functions that we haven’t typically done and training is essential in this kind of situation. And just as you had mentioned, Ellen, we may need to perform support staff duties, and an obvious fit for us would be helping in the dining room, because as we are helping residents eat and setting up their meals, we can do our assessments. There have been a number of tools developed to help promote intake and monitor, and we also need to move to virtual dietitian dysphagia training because we obviously can’t do the in-person side by side mentorship as we’ve done in the past. So, COVID-19 has placed us in a situation of needing to think progressively and creatively and we’ve developed a number of processes and tools and I’m very sure that some of these will endure into the future.

00:14:51 ➝ 00:15:21 B. Hopkins: Thank you Jean. Yes, that seems to be a common theme, doesn’t it. Some of these learnings, that we’re going to expect to see. Practice will be different in the future.

Ellen, how do you see, you know, coming back to you what you’re doing at Bruyère in complex continuing care. You talked already about a lot of things that have happened in terms of cross-functional roles and changes. How do you see the future of dysphagia care in your setting?

00:15:22 ➝ 00:16:45 E. Andrews: Thanks Bethany. I think this whole experience has really driven home things we knew before, but maybe we weren’t embracing fully, how important the strong interdisciplinary practice is. How important those relationship building in the team is, and within the professions themselves, while we do focus our work structure here, there’s sort of a unit-based approach, where it’s interdisciplinary, we have seen the importance of the professional groups too, banding together as a speech pathology group. How are we going to manage the services throughout this organization at this time when we’re not able to be doing our regular roles. So I think there’s been a lot of empowerment of the frontline staff and certainly a lot of acknowledgement from the leadership about our role in being flexible and being leaders in times of great change and great disruption. So I’m certainly hoping that going forward this may support other things we’ve been advocating for, instrumental dysphagia assessment in-house for instance, where we’ve been so limited on accessing services outside the organization. And just a continuing acknowledgment of the importance of sharing skills across disciplines and within groups, so that we are all ready, at all times, to jump into a variety of roles.

00:16:46 ➝ 00:17:02 B. Hopkins: Thank you Ellen, and Peter lastly thinking about your perspective on the future implications of COVID-19 in primary care and the community. Where do you see things going in that particular area?

00:17:04 ➝ 00:18:22 P. Lam: Bethany, I think what COVID-19 has done is actually taught us to become much more efficient and proficient clinicians. We need to be better prepared for when we are having assessments with individuals. I talked earlier, and as the other panelists have referred to, about the need to use technology to help us with communication. We now have the opportunity to use technology to have quick huddles with our colleagues. We are able to check-in with caregivers. We are able to check-in with patients in a much more efficient way now, compared to what we used to do. And I think in going forward, we need to embrace some of this technology and look at how this technology can actually help us in being able to provide service in a much more comprehensive way to the people we support.

00:18:24 ➝ 00:19:56 B. Hopkins: Thank you Peter, and as I’m reflecting on what all of you have said, there’s these key common themes about organization, efficiency, technology and really just new ways of working, new ways of working together that we’re going to see continue in the future and could lead to improvements in practice ultimately, down the road, which is nice to think of considering everything else that’s going on in our environment right now.

I want to thank each of you for sharing your thoughts and no doubt, our understanding about this pandemic and the implications for dysphagia practice is going to continue to evolve in the weeks, months and dare say years ahead as we learn more.

I do have one last question for each of your before we go, so our viewers can get to know you a little bit better. We’ve been talking about COVID-19, about the pandemic, and of course it’s been a source of stress and adversity for many people, and with this there’s been a lot of talk about the concept of resiliency, and what resiliency can do to help us adapt and make sense of these times. So I would like each of you to share with our listeners one tool, or one approach that you found personally helpful to be more resilient during these unprecedented times. So Ellen, I’ll start with you.

00:19:57 ➝ 00:20:39 E. Andrews: Thank you so much. I think I’ve reflected a few times already today on the different roles we’ve adopted during COVID. Another role I hadn’t mentioned is I’m a certified worker/member and co-chair of our joint health and safety committee. So through COVID I’ve had a very active role in working to promote the safety of my coworkers and my patients and my organization. I think having to step into that role and take that leadership, that chance to love and serve others through that role has strengthened myself. And I know I’m working to make my workplace and my colleagues safer, it helps me feel more secure in very, very stressful times. So I’ve been very grateful for that chance as well.

00:20:41 ➝ 00:20:48 B. Hopkins: Thank you Ellen. Peter. A tool or strategy that you have.

00:20:49 ➝ 00:22:08 P. Lam: Bethany, I think that the most important thing to remember is that we need to take care of ourselves. And so, one of the things that I’ve been doing is making sure that I don’t go crazy with booking my appointments by making them back to back, and taking that extra few minutes out in between seeing people online and virtually just to reflect on the fact that other people are in the same circumstance. It’s very important to put ourselves in their shoes to know how they’re feeling. Sometime it’s not just about the clinical appointment itself, but it’s even just the stress of not being able to see someone and recognizing that they’re only looking at this person on their computer monitor or iPad screen. It’s really important to realize that part of it, and become human in the screen for them.

00:22:10 ➝ 00:22:13 B. Hopkins: Thank you Peter. Jean, what have you found?

00:22:15 ➝ 00:23:30 J. Helps: Yeah, I think as I’ve been listening to Ellen and Peter, it occurs to me that one of the things that I think helps with resilience is simply working together and as a routine I’ve worked with my colleagues and it’s even more important now. But I’m going to share with you one tip that I think is related to looking after ourselves, and that is going out for walks in the woods with friends or family and there actually is a name for it. It’s called forest therapy. So I had no idea that I was actually engaging in something that has a name. But I have found that that’s extremely valuable for resilience and just carrying on with all of the things that we need to do. If I can just mention one other thing, and that is that I have faith in public health. I trust their expertise, and their messages. We are all in this together. We need to work together, and we will get through this.

00:23:31 ➝ 00:24:22 B. Hopkins: Thank you. Thank you. So, about loving and serving others, about keeping that human touch, that human factor. Taking time as well for ourselves, loving ourselves as much as loving others. I love the forest therapy, and here on the East coast, we get a little bit of ocean therapy from time to time as well, which is sort of similar. Thank you so much for sharing those insights. On that note, we will conclude this podcast. I’d like to thank you Peter, Ellen and Jean for joining us today, and I’d like to thank all of our listeners and viewers.

This concludes our episode of the Clinical Nutrition Notes podcast. For more podcast episodes, visit Clinical Nutrition Notes at NestleHealthScience.ca.