Update ASHA Guidance on Endoscopy and Prioritization of SLP Services during COVID-19
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ASHA's guidance suggests that endoscopy and videofluoroscopy be delayed. This guidance was written in March and is outdated given what we have learned about the virus and provision of skilled services for Speech-Language Pathologists. ASHA has also not taken a stance to help SLPs prioritize medically necessary procedures in a tier-style, to interpret what CMS has offered to help prioritize medical services. SLP services are being reduced and swallowing and voice diagnostics are being limited unnecessarily when we can safely provided medically necessary services. ASHA needs to do 2 things:
1) Update the statement on nasal endoscopy. Reference the AAO statement that the endoscopy itself is not the problem – it is the potential for a cough to aerosolize particles from a person with an active upper respiratory infection.
2) Engage with medical SLPs who are primarily clinicians to help create guidance documents like the CMS tiers for elective and outpatient procedures.
Full letter below.
Request to Update SLP guidance on Service Delivery Considerations during COVID-19
On March 13, 2020, the Coronavirus pandemic was declared by the President of the United States.
Healthcare services were drastically reduced in an effort to protect inpatient care beds and personal protective equipment (PPE) for a pending hospital surge. Medical professionals received guidance to limit non-urgent outpatient and elective procedures from the Centers for Disease Control and Centers for Medicare and Medicaid. Following that guidance, some SLPs clinics were temporarily closed, services were delayed, and some transitioned to telehealth service delivery models. Within a week, there was a new anecdotal report from the American Academy of Otolaryngology (AAO) which suggested a strong possibility that nasal endoscopy may lead to viral shedding in COVID-19 cases. Coupled with information that asymptomatic transfer of this dangerous virus was possible, many SLPs placed transnasal and rigid endoscopic procedures on an indefinite delay until more information about the virus was known. The guidance from ASHA, issued March 20, 2020, states as follows:
SLPs' Role in Endoscopic Procedures
CMS issued a guidance [PDF] on March 18, 2020 to limit non-essential adult elective surgery and medical, surgical procedures to conserve critical resources such as ventilators and Personal Protective Equipment (PPE), as well as limit exposure of patients and staff to the coronavirus. Based on the tiered framework of risk assessment that they propose, CMS recommends postponing completion of endoscopies. In further clarification to ASHA on March 20, 2020 CMS indicated that the guidance extended to Fiberoptic Endoscopic Evaluation of Swallowing (FEES). The heightened risk can be extended to completion of procedures such as flexible laryngoscopy with or without stroboscopy as well.
Since existing evidence indicates that viral density is greatest in the nose and nasopharynx, it is likely that use of instrumentation in and through these areas would lead to increased risk for transmission of COVID-19 in providers completing these tasks. Additionally, procedures such as FEES may involve the use of sprays, which can aerosolize the pathogens on the mucosa.
ASHA supports the guidance issued by CMS and is in favor of delaying endoscopic examinations as much as possible, while assessing transmission risk based on the CMS framework. We recommend that these procedures be performed only after pre-screening COVID-19 status and, performed only with appropriate PPE as recommended by the Centers for Disease Control (CDC). CMS guidance does provide reasons for furnishing the service based upon the needs of the patients. The rationale for completing the service would need to be documented by justifying why the procedure is critical at the present time for the patient. Per CMS communication with ASHA, clearly documented rationale is key.
An interesting discovery is that this statement appears to have remained consistent, without change, since its initial publication in March. There are no dates listed on the website to show when this statement was published since it is part of a much longer webpage that has added resources fairly regularly since that time. Given what was known on March 20, it made sense to wait until more was known about the virus, aerosolization, and PPE.
Guidance from the AAO and a report from Stanford (below) was released on March 21, which altered the practices of those who complete trans-nasal endoscopy for the next several days to weeks. Some SLPs have privately reported that they are still unable to complete trans-nasal endoscopic procedures such as Fiberoptic Endoscopic Evaluation of Swallowing (FEES) or Trans-nasal videostroboscopy / videolaryngostroboscopy (VLS). The SLPs reporting this information have continued to report limitations by facility administrators as recent as August 20, 2020.
The AAO issued guidance in March regarding tracheostomy care, endoscopy, and other ENT procedures. The suggestion from the Stanford report was that SARS-CoV-2 was spread to the staff of an operating room during a procedure that involved both nasal endoscopy and high speed drilling. The statement reads as follows:
“Otolaryngologists and surrounding staff are especially vulnerable to viral transmission directly through mucus, blood, and aerosolized particles when examining or operating in these areas. There is evolving evidence from China, Italy, and Iran that otolaryngologists are among the highest risk groupof contracting the virus while performing upper airway procedures and examinations if not using appropriate Personal Protective Equipment (PPE). This dilemma puts otolaryngologists in a difficult situation when presented with patients with time-sensitive and emergent problems that require surgery.”
The initial report from ENT physicians at Stanford was issued in March stating that there was concern for viral shedding during trans-sphenoidal surgery; the report stated that there was an “apparent high risk with endoscopic transnasal surgery” and went on to state that “in the clinic setting, we have similarly restricted visits to only urgent/emergent patients and have ceased the use of spray anesthetic/decongestants, opting instead for nasal pledgets as needed, but preferably avoiding endoscopy whenever possible.”
Since that time, the AAO has learned more about the transmission of SARS-CoV-2. Other medical organizations have issued statements that help to guide their professional members. The AAO issued an update on their statements in early May. Part one and Part 2 can both be found at the following webpage: https://www.entnet.org/content/covid-19-resource-page
On part one of this document, the AAO statement clarifies the following:
“Nasal endoscopy and flexible nasal laryngoscopy in and of itself are presumably not AGPs. However, they may potentially increase the likelihood of cough, gag, and sneeze, with possible subsequent aerosolization, and therefore appropriate precautions should be considered based on individual clinical circumstances.
“There are theoretical concerns of increased risk of transmission of COVID-19 infection when interventions involving the pharyngeal mucosa and the respiratory tract potentially cause aerosol generation in an actively infected individual. To date, there is no definitive evidence of transmission associated with specific otolaryngologic procedures. Although there is a published anecdotal report that suggested the theory that a high-speed drill may have caused transmission to healthcare workers during a pituitary surgery, this report was subsequently refuted by the primary surgical team who attributed all healthcare worker COVID-19 transmission to non-surgical care provided by staff who were not wearing appropriate PPE.”
This statement was issued May 7, 2020 and the AAO considers the above document a “living document,” so additional updates were added as of July 1, 2020, which did not alter the above statement.
The Centers for Medicare and Medicaid (CMS) issued guidance in the middle of March regarding prioritizing procedures, including tiers 1a-b, 2a-b, and 3a-b. The document can be found here: https://www.cms.gov/files/document/covid-elective-surgery-recommendations.pdf
Since that time, CMS has updated their tiered listing, which can be found here: https://www.cms.gov/files/document/cms-non-emergent-elective-medical-recommendations.pdf
These documents from our medical collaborators do not directly address what SLPs do for management of dysphagia. There will be patient circumstances, even during a pandemic with PPE shortages, where the situation meets the criteria for tier 3 – “lack of in-person treatment or service would result in patient harm.” Some patients might worsen without swallowing diagnostics to assist in selecting appropriate diets and therapy targets. Unmanaged dysphagia could place vulnerable, immune-compromised patients at risk of hospitalization, with symptoms that could mimic SARS-CoV-2 – cough, fever, shortness of breath. A vulnerable patient with these dysphagia symptoms could be hospitalized in a COVID unit which could increase his potential for exposure to this dangerous virus. Patients with symptoms that could mimic COVID should be considered for more urgent care than what ASHA has previously laid out.
It will be impossible for ASHA as a body to clarify all clinical circumstances that warrant tier 3 services vs tier 2 services. It seems that the CMS guidance on prioritizing procedures could have been used by SLPs based on the heading for tier 1-2-3 services on the CMS document.
The patients SLPs serve not always need immediate surgical intervention. However, by delaying their care in situation where dysphagia symptoms could mimic COVID-19, our patients are at risk of COVID-19 when they should be protected. The SLP profession can play a role in reducing hospitalizations and demands on the healthcare system if they will continue to do what they have always done. Provide appropriate evidence-based care for patients experiencing communication and swallowing problems, thereby enhancing quality of life, stabilizing or improving communication and/or swallowing, and providing necessary diagnostics to prevent worsening of these problems.
It is incumbent upon ASHA to be the organization that meets its members’ expectations. As a member of ASHA, I realize that it is the member’s responsibility to engage with the organization when those expectations have not been met.
Action items to request from ASHA:
1. Update the statement on nasal endoscopy. Reference the AAO statement that the endoscopy itself is not the problem – it is the potential for a cough to aerosolize particles from a person with an active upper respiratory infection.
Why: There are SLPs and administrators who are still referencing the ASHA guidance document from March, suggesting that they are cleared to do videofluoroscopy (VFSS) but not cleared to do endoscopy (FEES). Unfortunately, there are clinical circumstances where a FEES might be more appropriate compared to a VFSS. A FEES also involves fewer personnel than a VFSS and could potentially decrease the need for a radiology suite to be closed following the procedure. Clinicians have had their FEES scopes permanently stopped “due to the pandemic.” This information is outdated and clinically incorrect. Patients are missing the opportunity to have this dynamic exam, delaying and complicating care. SLPs are turning to practices that are not evidence-based, such as treating pharyngeal dysphagia without imaging. They may also be missing critical information that a FEES will provide compared to VFSS, when their clinical recommendation would typically be to complete a FEES. This has to stop, now.
2. Engage with medical SLPs who are primarily clinicians to help create guidance documents like the above sample table of the CMS tiers for elective and outpatient procedures.
Why: The medical profession has come together across their many organizations to determine how to apply these tiers of service delivery to their profession. The AAO documents (part one and two) above are prime examples of this adaptation. ASHA as a body of members can come together and issue guidance. If we see waves of COVID-19 and surges in our hospital systems, SLPs will need guidance that is a consensus-based document to reference on prioritizing services.
SLPs are the first line for assessment and intervention for dysphagia. By keeping the statement on nasal endoscopy unchanged from March 2020, not including a date on the guidance that is listed on the website, and by ignoring service provision prioritization on the ASHA information on COVID-19, SLPs are finding that their organization does not represent the membership and we lack the power to go to our administrators with information that will keep SLPs serving their patients, when it’s appropriate and medically indicated.
If ASHA as a body is able to engage with medical SLP members who are “boots on the ground” professionals dealing with how to work with our patients during a pandemic, ASHA will find that their guidance more accurately reflects how SLPs are practicing in the real world.
I want ASHA to ensure that the members they consult with on this information are actively engaged in completing endoscopy and prioritizing in-person clinical care, versus those who are not trained in endoscopy and completing nearly all telehealth visits at this time. The clinicians completing in-person medically necessary care are seeing what is happening as a direct result of their actions to help patients.
Thank you for listening.
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