Virginia Regulatory Town Hall View Comments

Department of Health Professions

Board of Audiology and Speech-Language Pathology

Regulations of the Board of Audiology and Speech-Language Pathology [18 VAC 30 ‑ 20]

Action	Requirements for practice of fiberoptic endoscopic evaluation by speech-language pathologists
Stage	NOIRA
Comment Period	Ended on 2/2/2011

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2/2/11 12:17 am

Commenter: Carla DeLassus Gress

Proposal to regulate endoscopy by SLPs

I strongly support and welcome the Board’s efforts to regulate the performance of endoscopic procedures by Speech-Language Pathologists (SLPs) in Virginia.

The Flexible Endoscopic Evaluation of Swallowing (FEES®)procedure[1] represents an advanced practice activity performed by SLPs. Instruction in the technique and interpretation of the FEES® protocolis generally not part of the masters’ level preparation to become an SLP, and competency must be developed through continuing education and ongoing training. There are potential risks to patients who undergo this procedure. It is therefore in the best interest of SLPs and their patients for the Board to regulate these practices to provide for optimum safety.

There are additional instrumental procedures which may be utilized by the SLP to assess functional speech, voice, and swallowing, including laryngeal stroboscopy (also performed with an endoscope), fluoroscopic evaluation of swallowing (aka modified barium swallow studies or MBS), and surface EMG (eg, VitalStim). As technology develops, there will likely be additional instrumental procedures that SLPs will utilize to optimize patient management. As is the case with FEES®, these procedures may carry potential risks to patients. Therefore, it is suggested that regulations which address the FEES® procedure be written in a generalized manner to include all instrumental procedures that a SLP may perform as an advanced practice, rather than developing regulations for each procedure individually in a piecemeal fashion in response to complaints or concerns.

Any regulations that are developed should emphasize the collaborative approach of SLPs and their physician colleagues in patient management. Some of these instruments are used by physicians to detect and diagnose medical conditions and diseases. Use of these instruments by SLPs is restricted to the assessment and treatment of speech, voice, and swallowing disorders for the purpose of SLP therapeutic intervention. SLPs are not qualified or licensed to diagnose medical conditions or diseases, and regulations should make a distinction in the use of these instruments by physicians as opposed to their use by SLPs.

In Virginia, nurse practitioners and physician assistants are “advanced practice” professionals who perform some of the same procedures as physicians, but work collaboratively and under the supervision of physicians. The VA licensure laws regulating these professions may serve as a model for developing regulations for the advanced practice of SLPs, particularly in reference to supervision requirements.

The Tennessee laws which govern the performance of endoscopic procedures (including FEES® and laryngeal stroboscopy) specify training requirements of 1) dedicated instruction (university coursework or continuing education program of 15 hours) and 2) performance of 25 supervised endoscopic procedures. However, there is no evidence that completion of these requirements will ensure competency of the SLP practitioner, and in fact, these numbers are completely arbitrary. There are a number of training models by which an SLP could develop competency in endoscopy. For example, online instruction focused primarily on exam interpretation, coupled with abbreviated hands-on training in the use of the endoscope; or computerized models which simulate manipulation of the scope paired with videotaped examples for interpretation of findings. Our regulations should not identify a particular training model as the preferred model in the absence of data to support its superiority.

The crucial issue is, of course, the competency of the SLP in performing a procedure, which includes skill in the use of the instrument and (equally if not more importantly) the interpretation of the findings. ASHA has developed peer-reviewed knowledge and skill requirements (competencies) for the performance of laryngeal stroboscopy, endoscopic evaluation of swallowing, and modified barium swallow studies, as well as a number of guidance documents regarding the use of instrumental procedures. The knowledge and skills outlined in the ASHA documents form the basis for assessing clinical competency in this specialized area of practice and provide a clear standard for training and practice. Adherence to the ASHA competencies could serve as the criteria by which judgments can be made by the Board regarding the adequacy of training.

SLPs most often collaborate with otolaryngologists in the care of patients with speech, voice and swallowing problems. However, there are other physician specialists who are knowledgeable in the anatomy and physiology of the speech, voice, and swallowing mechanisms, and are skilled in performing endoscopy. These include non-otolaryngologist head & neck surgeons, pulmonologists, radiation oncologists, and gastroenterologists. Further, board-certified otolaryngologists may specialize in various aspects of their profession, such as disorders of the sinus or cochlear implants, and have minimal expertise in the evaluation of speech, voice and swallowing disorders. While in general, a “board-certified” otolaryngologist may be the preferred specialist for supervision of SLPs performing endoscopic procedures, supervisory functions should not be limited to “board-certified otolaryngologists” (as dictated by the Tennessee document) or restricted to “otolaryngologists”. To include regulations to that effect would, in essence, restrict the practice of other qualified physician specialists who may have interest in training and supervising SLPs in endoscopic procedures. The BASLP may need to seek legal guidance regarding its ability to impose restrictions on the practice of non-ENT physicians before adopting the Tennessee document.

There are several provisions in the Tennessee document that should be incorporated into our regulations to facilitate patient care, promote MD-SLP collaboration, and ensure patient safety. These include 1) the requirement for obtaining a physician referral specific to the instrumental procedure, 2) the need to report findings to the referring physician, and 3) the necessity of a protocol for emergency medical back-up.

Many thanks for your efforts to establish a safe environment for our patients by addressing these issues. If I may be of any assistance, please do not hesitate to contact me.

Regards,

Carla DeLassus Gress, ScD, CCC-SLP

University of Virginia

Charlottesville

Home address: 3520 Rocks Mill Lane, Charlottesville, VA 22903

CarlaGress@Virginia.edu

[1]Langmore SE, Schatz K, Olsen N. Fiberoptic endoscopic examination of swallowing safety: a new procedure. Dysphagia 1988;2:216–219

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CommentID: 14984