February 2, 2011 

Ms Knachel, Ms Yeatts and members of the Board of Audiology and Speech Language Pathology of the Commonwealth of Virginia (BASLP).

As a practicing speech language pathologist (SLP), in a large health care system, where Flexible Endoscopic Evaluation of Swallowing (FEES) is part of routine care, I agree that the licensing board for audiology and speech pathology should adopt practice regulations in order to establish guidelines for SLP training, supervision, and practice of this procedure. This skill does require advanced education and training, which are necessary to ensure quality patient care and safety.  I recognize that state regulated guidelines, referencing national standards for training and education, knowledge and skills, and the ethics of providing competent care, can be an invaluable resource, for practicing clinicians, referring physicians, and also regulatory board members, in providing information to the public and patient advocates.

ASHA’s position statement of 2005 states that performance of FEES procedures is within the scope of practice for SLPs who have expertise in dysphagia and specialized training in flexible endoscopy. ASHA states that SLPs are “…qualified to use this procedure independently for the purpose of assessing swallow function and related functions of structures within the upper aerodigestive tract,” and that FEES is “…not intended to replace the fiberoptic examination of swallowing [by an MD] and/or assess the integrity of the laryngeal and pharyngeal structures in order to render a medical diagnosis.”  Several states have adopted regulations and guidelines in accordance with this national standard, e.g. http://www.op.nysed.gov/prof/slpa/speechguidefiberoptic.htm 

In the past two years Flexible Endoscopic Evaluation of Swallowing has become an integral part of my practice, determining safety for patients during medical recovery, providing documentation of risk for patients, families and physicians, and contributing to decision-making by the team for aggressive or, alternatively, palliative care.  As I described at the BASLP meeting in August 2010, before performing FEES independently we at UVA Health System Medical Center have received 12 hours of classroom instruction, one-on-one hands-on demonstration and then supervision by a trained, competent dysphagia endoscopist for a minimum of 25 procedures initially, and continued monitoring over the first twelve months, with a further annual review of practice standards, research updates and analysis of case study imaging.  This is a comprehensive program of instruction, designed by leaders in the field, and describing one avenue for developing skill and competence with performing the FEES procedure.

In our acute medical care setting FEES provides the opportunity for nurses, physicians, respiratory therapists and the code team to be in close vicinity to the SLP independently performing examination of swallowing, thus facilitating patient monitoring, and observation if indicated, often in the same areas where bronchoscopies, tracheostomies and gastrostomies are performed. SLPs across the country perform FEES in rehabilitation, nursing facilities and outpatient clinics with physicians available and emergency plans in place.  Complication rates of FEES examinations in the literature are very low.  Langmore and Aviv (2000, 2000) have each conducted studies with thousands of FEES examinations performed, showing there have been no serious complications during FEES performed by SLPs.

Our ASHA Code of Ethics states that all SLPs “…shall provide all services competently.”  As practicing health care providers we are bound by our code of ethics to pursue education and training and to only provide services we are each individually competent to perform.   Regulation and guidelines, developed by BASLP in collaboration with SLPs practicing FEES and knowledgeable with regard to current research in the field, would facilitate adherence to the code and provide for reporting and sanctioning as necessary.

I urge the Board of Audiology and Speech Language Pathology of the Commonwealth of Virginia to consider the work done nationally and in other states regarding SLP FEES practice and regulation, and to enlist the services of trained SLPs practicing FEES, in the various settings in which clients and patients are treated, in the development of regulation and guidelines for the Commonwealth of Virginia.  I look forward to participating in discussions with SHAV and VSO members to this end.

Thank you for your considerate attention to this important matter.

Respectfully submitted,

Catherine M. Reynolds, M.A. CCC-ACE-SLP

Clin 3 Acute Medcial Care SLP,

Therapy Services,

University of Virginia MedicalCenter

Cr6j@Virginia.edu