The New Zealand Speech-language Therapists’ Association (NZSTA)

Competency Framework:

Flexible endoscopic evaluation of swallowing (FEES)

Copyright © 2018 The New Zealand Speech-language Therapists’ Association

Disclaimer: To the best of The New Zealand Speech-language Therapists’ Association’s (‘the Association’) knowledge, this information is valid at the time of publication. The Association makes no warranty or representation in relation to the content or accuracy of the material in this publication. The Association expressly disclaims any and all liability (including liability for negligence) in respect of use of the information provided. The Association recommends you seek independent professional advice prior to making any decision involving matters outlined in this publication.

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3 FEES competencies

3.1 Basic FEES Interpretation (Level 1)

Competency to be gained/maintained within workplace context

Consistent evidence provided to supervisor Date completed & supervisor signature (sign-off)

Recognise when instrumental assessment of swallowing is indicated

Identify pros and cons of FEES vs. Videofluoroscopic study of swallowing (VFSS)

Identify contraindications for FEES Identify the clinical boundaries of and procedures performed

by SLT and/or ORL Identify normal pharyngeal & laryngeal anatomy as viewed

via an endoscope. Identify where nasal, velopharyngeal, pharyngeal and

laryngeal anatomy requires further assessment by a medical practitioner

Interpret basic FEES findings including secretion rating, residue and aspiration status

Knowledge of NZSTA FEES Standards of Practice and Competency Framework and local FEES policy

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3.2 Advanced FEES Direction (of Procedure) and Interpretation (Level 2)

Competency to be gained/maintained within workplace context

Consistent evidence provided to supervisor Date completed & supervisor signature (sign-off)

Able to provide the patient, medical team and if appropriate family/whānau with a description of the procedure, associated risks and FEES rationale, for the purpose of obtaining informed consent

Able to prepare the patient and environment for FEES procedure, including ensuring appropriate food and fluid preparations, audio visual recording equipment, lubrication of scope/nasal cavity and patient positioning

Provide clear instructions to the patient throughout the FEES in order to obtain a full examination of the velopharynx, pharynx and larynx

Select appropriate patient postures, swallowing manoeuvres and bolus modifications to evaluate swallowing function, based on the patients performance during the examination

Direct other staff involved in the procedure as required, including informing endoscopist of image requirements for FEES as necessary

Manages/describes how to effectively manage adverse patient events/reactions that may occur in relation to FEES procedures

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Competency to be gained/maintained within workplace context

Consistent evidence provided to supervisor Date completed & supervisor signature (sign-off)

Provides accurate and complete FEES reports in line with NZSTA FEES reporting standards, within a timely manner as per local policy. Reports should include:

Identification of atypical anatomy and physiology and evaluate its impact on swallowing function

Identification of when review of abnormal anatomy by a medical practitioner is indicated

Description of bolus passage across consistencies as viewed endoscopically, including bolus position at swallow onset, symmetry of bolus flow, volume, location and response to residue and/or aspiration

Concise FEES summary/impression with key findings and hypothesised links with underlying impaired swallowing physiology and resulting symptoms

Recommendations for diet/fluid provision/modification, rehabilitation programmes, timing of repeat assessment, further investigations and onwards referrals e.g. ORL

Use FEES as a rehabilitation tool including teaching compensatory strategies via bio-feedback.

Communicate FEES findings to patient, medical team and family/whānau.

Timely and secure handling/storage of patient information in line with local standards, including consent forms, formal reports, clinical documentation, video recordings, FEES log completion etc.

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3.3 Basic Endoscopy for FEES (Level 3)

Competency to be gained/maintained within workplace context

Consistent evidence provided to supervisor Date completed & supervisor signature (sign-off)

Ensures equipment is in working order and endoscope has undergone appropriate decontamination as per local policy

Recognise high risk, complex patients and those not appropriate for SLT-led endoscopy

Recognise normal nasal, velopharyngeal, pharyngeal and laryngeal anatomy as viewed via endoscope

Recognise nasal, velopharyngeal, pharyngeal and laryngeal anatomy requiring further assessment by a medical practitioner, as viewed via endoscope

Pathway 2 only Requires minimal feedback in order to achieve optimal

visualization and patient comfort during endoscopy including: Demonstrates problem-solving and optimal nasal cavity

selection to ensure maximal comfort for the patient Able to insert endoscope through nasal cavity via an

appropriate route Able to maintain an optimal view and pace whilst

demonstrating full awareness of scope location during passage through the nasal cavity

Able to maintain a static position in the pharynx whilst maximising patient comfort

Able to manoeuvre the endoscope during FEES to obtain desired views including cleaning the scope tip in situ

Able to remove endoscope with minimal patient discomfort Aware of when the endoscope should be removed during a

FEES

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3.4 FEES Competent (Level 4)

Competency to be gained/maintained within workplace context

Consistent evidence provided to supervisor Date completed & supervisor signature (sign-off)

Pathway 2 only Able to independently perform endoscopy for high risk and

complex patients (see NZSTA FEES Practice Standards)Pathway 2 only Able to independently perform endoscopy for the purpose of

biofeedback during swallowing rehabilitationPathway 2 only Able to consistently and independently achieve optimal

visualisation and patient comfort during endoscopy including; Demonstrates optimal nasal cavity selection to ensure

comfort for the patient is maximised. Able to insert endoscope through nasal cavity via an

appropriate route whilst maintaining an optimal view and pace, and demonstrating full awareness of scope location during passage through the nasal cavity

Able to maintain a static position in the pharynx whilst maximising patient comfort

Able to manoeuvre the endoscope during FEES to obtain desired view including cleaning the scope tip in situ

Demonstrates independent and consistent problem-solving to ensure a full assessment is completed under endoscopy

Able to remove endoscope with minimal discomfort Aware of when the endoscope should be removed during a

FEES Able to consistently and independently provide clear

instructions and reassurance to maximise patient tolerance of the procedure

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3.5 FEES Trainer (Level 5)It is an expectation that a period of consolidation of skills occurs prior to working towards training others in FEES. This period of time will vary according to many factors and line manager sign off is required prior to embarking on level 4 training to ensure all pre requisite skills have been met. Line managers should seek support from level local or national 5/6 FEES clinicians where required.

Competency to be gained/maintained within workplace context

Consistent evidence provided to supervisor Date completed & supervisor signature (sign-off)

Provide appropriately paced, structured training in line with service demands

Appreciate different learning styles and pace of learning, appropriately modify own teaching style to meet the needs of the supervisee

Able to select appropriate timing and method of feedback delivery to maximally support supervisee and maintain safety in regards to endoscopy, FEES direction, interpretation and report writing

Able to determine when a competency has or has not been appropriately demonstrated and provide appropriate and accurate feedback to the supervisee

Identify when additional support might be beneficial to maximally support the supervisee including different sources/approaches of support

Seek out opportunities to receive feedback in regards to own ability to provide FEES training, and demonstrate reflective practice

Maintains own NZSTA e-portfolio e.g. self-reflections, training logs & audits

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3.6 New Zealand FEES Advisory Group (Level 6)

Competency to be gained/maintained within workplace context

Consistent evidence provided to supervisor Date completed & supervisor signature (sign-off)

In addition to a minimum of two of the below : Maintains own NZSTA e-portfolio e.g. FEES self-reflections,

FEES training logs & FEES audits Extensive knowledge or participation in FEES research or

journal publications National/international level presentation/teaching pertinent

to FEES Active contribution to national FEES support &

development//SIG-based learning Nomination by two other Level 6 clinicians to attest to the

level of FEES skills

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4.1 FEES clinical audits

Level 1 FEES clinical audit

Performance criteria Completed Yes/No

Comments

Identified patient was appropriate for FEES and was able to articulate why

Described the risks and benefits of FEES to the patient, whānau/family and medical teamDescribed the procedure and its purpose to the patient and/or whānau/familyObtained informed consent for procedure from the patient and/or whānau/familyRecognised normal and grossly abnormal laryngeal anatomy as viewed via endoscopeInterpreted basic FEES findings including secretion, residue and aspiration status Was able to make appropriate recommendations on safety and effectiveness of swallowing based on findings of FEES assessment

Audited SLT name: Auditing FEES competency level:

Auditing SLT name: FEES Competency Level ___ achieved/not achieved

Auditing SLT designation: Auditing SLT signature:

Audited SLT signature:

Date:

(Adapted with permission from Waitemata District Health Board, 2018)

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Level 2 FEES clinical audit

In addition to all elements in Level 1 the following criteria must be met to achieve Level 2 competency

Performance criteria Completed yes/no

Comments

Effectively manages patient–related factors such as anxiety and physical discomfort to optimise patient safety and comfortProvide clear instructions to enable patient to participate in the examinationContribute within scope of practice to the FEES procedure e.g. feeding patient, providing endoscopist with equipment as requiredSelect appropriate patient postures, swallowing manoeuvres and bolus modifications to evaluate swallowing function, based on the patient’s performance during the examinationIdentify atypical anatomy and physiology and evaluate its impact on swallowing function during the FEES procedure and make onward referral to appropriate service(s)where indicatedDescribe swallowing function with regards to bolus management and swallowing physiology, as seen on endoscopyIndependently select appropriate treatment and management strategies based on FEES findingsOnline evaluation of the effects of these treatment and management strategies on swallowing functionDetermine likely underlying impairments based on FEES presentation, and formulate an appropriate treatment plan including re-assessment and referral to other discipline(s) as indicated Make recommendations for safe texture and fluid consistencies, recommendations regarding management of secretions and/or a rehabilitation plan based on FEES assessment

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Performance criteria Completed yes/no

Comments

Communicate findings of the FEES procedure to the patient, whānau/family and medical teamDocument key findings and any change in recommendations in clinical record immediately after procedure (or as per local policy)Disseminate report to relevant health professionals in a timely mannerAudited SLT name: Auditing FEES competency level:

Auditing SLT name: FEES Competency Level ___ achieved/not achieved

Auditing SLT designation: Auditing SLT signature:

Audited SLT signature:

Date:

(Adapted with permission from Waitemata District Health Board, 2018)

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Level 3 FEES clinical audit

In addition to all elements in Level 1 the following criteria must be met in order to achieve Level 3 competency

Performance criteria Completed yes/no/NA

Comments

Identify complex patients and patients not appropriate for endoscopyEnsure patient is appropriately positioned for optimal viewing of the oro-pharynx and for maximal comfort during the procedurePerform endoscopy procedure in accordance with local infection and control policies and proceduresAble to pass an endoscope under direct supervision, with non-complex patients, and maintain an adequate view for FEES whilst ensuring maximal patient comfort Audited SLT name: Auditing FEES competency level:

Auditing SLT name: FEES Competency Level ___ achieved/not achieved

Auditing SLT designation: Auditing SLT signature:

Audited SLT signature:

Date:

(Adapted with permission from Waitemata District Health Board, 2018)

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Level 4 FEES clinical audit

In addition to all elements in Level 1, 2 and 3 the following criteria must be met in order to achieve Level 4 competency

Performance criteria Completed yes/no/ NA

Comments

Effectively manage endoscope or image defects to maximise the desired view independently Demonstrate independent and effective endoscopy technique in order to cause minimal discomfort to the patient and in order to visualise the velopharnyx, oropharynx, pharynx, larynx and laryngopharynxDirect other staff involved in the procedure whilst completing endoscopy as requiredConsistently and independently provides clear instructions and patient reassurance during the procedure to maximise toleration of the procedureDemonstrate independent and consistent problem-solving to ensure thorough assessment is completed under endoscopy

Audited SLT name: Auditing FEES competency level:

Auditing SLT name: FEES Competency Level ___ achieved/not achieved

Auditing SLT designation: Auditing SLT signature:

Audited SLT signature:

Date:

(Adapted with permission from Waitemata District Health Board, 2018)

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Level 5 FEES clinical audit

In addition to all elements in level 1, 2, 3 and 4 the following criteria must be in order to achieve Level 5 competency

Performance criteria Completed yes/no

Comments

Demonstrate effective coaching/supervision and training to a FEES superviseeDemonstrate knowledge and understanding of varied adult learning principlesDemonstrate the ability to appropriately modify own teaching style to meet the needs of the superviseeDemonstrate the ability to select appropriate timing and method of feedback delivery to maximally support supervisee and maintain safety in regards to endoscopy, FEES direction, interpretation and report writingDemonstrate the ability to determine when a competency has or has not been appropriately demonstrated and provide appropriate and accurate feedback to the superviseeIdentify when additional support might be beneficial to maximally support the supervisee, including different sources/approaches of support Audited SLT name: Auditing FEES competency level:

Auditing SLT name: FEES Competency Level ___ achieved/not achieved

Auditing SLT designation: Auditing SLT signature:

Audited SLT signature:

Date:

(Adapted with permission from Waitemata District Health Board, 2018)

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