Renee Kinder

Impacts of intubation and mechanical ventilation.

Medical complexities including cardiac and respiratory disease.

Risk for pneumonia, aspiration, and increased length of stay.

What do all of these areas have in common?

They are all variables which contribute to increased risks for dysphagia in persons recovering from COVID-19.

Thankfully, post-acute care focus on swallow assessment and rehabilitation has improved since the implementation of the Patient Driven Payment Model, and collaborative nursing and therapy team coding of Section K0100 of the Minimum Data Set, which impacts HIPPS and specifically speech pathology case mix groupings.

Need a refresher of K0100 A-D descriptions?

  • K0100A, loss of liquids/solids from mouth when eating or drinking
  • K0100B, holding food in mouth/cheeks or residual food in mouth after meals
  • K0100C, coughing or choking during meals or when swallowing medications
  • K0100D, complaints of difficulty or pain with swallowing

In the absence of COVID-19, we know that historical research has found the following to be true regarding swallow function:

  • Patients over 75 had double risk of dysphagia associated with hospitalization
  • Patients with dysphagia had 40% longer length of stay (LOS) than patients without dysphagia
  • Patients with dysphagia undergoing rehabilitation have a 13-fold increase in mortality than those without dysphagia
  • The presence of COPD was shown to be the most significant risk factor for aspiration pneumonia in nursing home patients

What I want to bring awareness to today is the fact that many of the COVID-19 risk factors, interventions, and recovery paths can further compound the ability of many persons to swallow and maintain nutritional status once they reach our care in skilled nursing facilities.

Let us start with how Medicare defines dysphagia.

Medicare Benefit Policy Manual Chapter 15 defines dysphagia as difficulty in swallowing, which can cause food to enter the airway, resulting in coughing, choking, pulmonary problems, aspiration or inadequate nutrition and hydration with resultant weight loss, failure to thrive, pneumonia and death.  

Most often, dysphagia is due to complex neurological and/or structural impairments, including head and neck trauma, cerebrovascular accident, neuromuscular degenerative diseases, head and neck cancer, dementias and encephalopathies. 

For these reasons, Medicare states it is important that only qualified professionals with specific training and experience in this disorder provide evaluation and treatment. 

Swallowing assessment and rehabilitation are highly specialized services. The professional rendering care must have education, experience and demonstrated competencies. 

Competencies include, but are not limited to: identifying abnormal upper aerodigestive tract structure and function; conducting an oral, pharyngeal, laryngeal and respiratory function examination as it relates to the functional assessment of swallowing; recommending methods of oral intake and risk precautions; and developing a treatment plan employing appropriate compensations and therapy techniques.

Do you notice any commonalities above with what we know to place individuals at risk for COVID-19?

Respiratory function 

Add to this the fact that there is a period of apnea that occurs during the swallow, in addition to changes in breath patterns which are present during intake, making mealtime experiences more challenging for individuals with reduced respiratory functions.

More complications to consider as we develop mealtime care plans in the absence of community group dining.

Now let’s shift to further considerations with individuals recovering from COVID-19.

People recovering from COVID-19 present with many risk factors associated with requirements for mechanical ventilation through an artificial airway.

As such, when patients transition from acute-care settings into the post-acute spectrum providers are faced with the clinical care challenges associated with impacts of intubation and mechanical ventilation

In Dr. Anthony Fauci’s January 2020 Journal of the American Medical Association (JAMA) publication Coronavirus Infections — More Than Just the Common Cold it was initially reported that common symptoms of SARS included fever, cough, dyspnea, and occasionally watery diarrhea. Of infected patients, 20% to 30% required mechanical ventilation and 10% died, with higher fatality rates in older patients and those with medical comorbidities.

Prolonged endotracheal intubation is a common cause of dysphagia swallowing disorders.

So, you see, these risk factors (respiratory disease), and care paths (ventilation) only act to complicate and compound the oropharyngeal swallow process.

What can SNFs do to prepare?

To begin, be informed of all procedures that occurred during the acute-care process, including the desired path for weaning and recovery.

Second, consider what we learned with the shift to PDPM and the impact of medical complexities on function. If anything, the movement to a more clinically focused care model pre-pandemic has only taught us to appreciate comorbidities and their impact on function.

When it comes to dysphagia and COVID recovery there is a clear impact of compromised respiratory systems on the overall ability to swallow and maintain nutrition and hydration. 

Discuss findings of bedside swallow evaluations with your speech language pathologists and seek records from any instrumental assessments such as modified barium swallow studies completed during the acute-care stay. 

In the absence of community dining opportunities, consider the impacts of positioning and maintaining appropriate positioning during mealtime intake and coordinate with your physical and occupational therapists for guidance. 

And finally, as we would outside of the PHE, plan in an interdisciplinary manner for care. Be gracious and thankful to all members. The road ahead for SNFs and patient recovery may be a long one. 

To those on the front lines, we appreciate you and your service daily. 

Renee Kinder, MS, CCC-SLP, RAC-CT, is Vice President of Clinical Services for Broad River Rehab and a 2019 APEX Award of Excellence winner in the Writing–Regular Departments & Columns category. Additionally, she serves as Gerontology Professional Development Manager for the American Speech Language Hearing Association’s (ASHA) gerontology special interest group, is a member of the University of Kentucky College of Medicine community faculty, and is an advisor to the American Medical Association’s Relative Value Update Committee (RUC) Health Care Professionals Advisory Committee (HCPAC).