Introduction: Dysphagia in Intensive-Care-Unit Acquired Weakness (ICUAW) is multi-factorial, with a major precipitating factor being weakening of the oropharyngeal musculature. However, the evidence base for dysphagia rehabilitation in ICUAW is currently lacking. We propose that a multi-modal strength-based rehabilitation training program, initiated within the ICU, may be effective in supporting dysphagia rehabilitation within this clinical population.

Aim(s): To determine the feasibility, safety and effectiveness of a strength-based dysphagia treatment protocol for patients with ICUAW and dysphagia.

Methods: All patients admitted to Concord Hospital ICU (March 2021-2023), diagnosed with dysphagia and ICUAW were considered for inclusion. Clinical Swallow Examination (CSE) and Flexible Endoscopic Evaluation of Swallowing (FEES) confirmed diagnosis and severity of dysphagia. A strength-based dysphagia treatment protocol was implemented targeting the tongue-base, pharyngeal, suprahyoid and respiratory muscles. Haemodynamic monitoring was undertaken during each treatment session to ensure safety. Key swallowing and respiratory outcomes were collected weekly including: CSE (Functional-Oral-Intake-Scale), FEES (New-Zealand-Secretion-Scale, Penetration-Aspiration-Scale, Yale pharyngeal-residue-scale), Peak Expiratory Flow (PEF) and Maximum Expiratory Pressure (MEP). Nutritional outcomes (Indirect Calorimetry) were collected monthly.

Results: Nine participants (7-male, mean age=60years) have been recruited to date. Medical diagnoses include severe burn injury, COVID-19 and Influenza-A. All participants exhibited profound dysphagia on initial examination, completed the treatment protocol and achieved premorbid diet and fluids (with/without compensatory strategies) by hospital discharge. There were no adverse events during treatment delivery.

Conclusions: A strength-based dysphagia treatment protocol for patients with ICUAW and dysphagia is safe, feasible and effective with promising outcomes to expedite dysphagia recovery in this challenging population.

Introduction: Stroke guidelines internationally recommend early screening of swallowing post-stroke. The target timeframe in Australian and UK guidelines is within 4-hours of the patient’s presentation to hospital.

Aims: To determine compliance with the 4-hour target timeframe for swallow screening, determine enablers and barriers to meeting the target, and patient outcomes of not meeting the target in one metropolitan hospital in Adelaide, South Australia.

Methods: The mixed-methods knowledge-translation approach included: quantitative measures of compliance at numerous timepoints; semi-structured interviews with 10 nurses, 2 medical officers and 2 speech pathologists mapped to the Theoretical Domains Framework; medical record audit of patient outcomes; and patient interviews about their experience when the timeframe was not met.

Results: Compliance for swallowing screening within 4-hours March 2018-February 2019 was 56% (n=203/365). Barriers were overnight admissions and admissions to wards other than the dedicated stroke unit. Enablers were strong beliefs about patient benefits, confidence in the screening tool and nurse training and capabilities. Compliance improved to 80% (n=35/44) when audited again May-August 2021. For 10 patients who did not have swallowing screening within 4-hours, average wait time was 10.5-hours and only half adhered to NBM status while awaiting screening. There were no adverse events, but six patients interviewed reported hunger, thirst, agitation and frustration at missing medications. The most recent audit July-September 2022 revealed 90% compliance.

Conclusions: Involving clinicians and patients in feedback cycles and exploration of context, saw compliance with swallow screening target timeframes improve significantly, providing a blue-print for other stroke units to replicate.

Keywords: Swallowing; Screening; Stroke; Guidelines; Implementation science; Patient experience

Submission Statement:

As reflective practitioners, we undertook this research to continually improve our approaches to practice in stroke. We did so collaboratively with clinicians from multiple disciplines and with our patients to truly respect and respond to their needs and experiences.

Introduction/rationale: Oesophageal screening (OS) is a valuable inclusion in videofluoroscopic swallow studies (VFSS), however routine standardised OS is not widely occurring in clinical practice.
Aim(s): 1) To introduce an OS protocol in a diverse VFSS cohort at one Australian tertiary hospital, 2) To evaluate the introduction of the OS protocol using the Theoretical Domains Framework (TDF).
Methods: Radiology, gastroenterology, and speech pathology (SP) endorsed the OS protocol. Measures exploring operational and clinical impacts were recorded and mapped to the TDF to identify barriers and enablers. These impacts were compared to 100 VFSS consecutive patients before the OS protocol introduction.
Results: One hundred and sixty patients were recruited to the OS protocol trial group. Rates of OS significantly increased (X² = 63.462, p < .001) and consistency of OS improved with the introduction of the OS protocol compared to pre-trial. In the OS protocol trial group, there was nil significant difference in radiation dose for patients who had OS compared to patients who did not (U = 1689.000; p = .237). In the OS protocol trial group, SP reported delayed oesophageal transit significantly more often than radiology (54% vs. 28%, X² = 28.842, p < .001). Enablers to the OS protocol included the environmental context and resources, knowledge, and skills domains. Barriers to the OS protocol included professional role, and memory, attention, and decision-making domains.
Conclusions: Nil adverse operational impacts occurred with the introduction of the OS protocol. Solutions to the barriers identified require further consideration by the multidisciplinary dysphagia team.

Key words: dysphagia, videofluoroscopic swallow studies, oesophageal screening

Submission statement: This study reflects on current VFSS protocols and best practice standards. It aims to provide safe, efficient, and clinically valuable VFSS services to patients, through respectful collaboration with multidisciplinary dysphagia partners. This study also aims to respond to emerging research by evolving and innovating VFSS practice.

Introduction/rationale:
The evidence base is constantly evolving and there have been numerous updates to the evidence in videofluoroscopic swallowing studies (VFSS) particularly in regard to what is considered a ‘normal’ swallow. Feedback obtained from speech pathologists at Eastern Health (EH) highlighted the need for this evidence to be embedded into the department’s VFSS interpretation tool to ensure that pathology can be accurately described against what is understood to be ‘normal physiology’.

Aim(s):
The development of a VFSS interpretation tool that includes normative swallowing data with an emphasis on swallow function over impairment.

Methods:
Benchmarking was conducted with other health networks across Australia. The Eastern Health
(EH) Speech Pathology (SP) team were surveyed regarding specific perspectives on the current VFSS interpretation tool. A critical appraisal of topic was conducted to review the current evidence base regarding normal swallowing measures.

Results:
The current evidence and information gained from benchmarking demonstrated that no single VFSS interpretation tool incorporates swallowing norms and is also validated, reliable and accessible.
Given the absence of a comprehensive tool that could be easily incorporated into practice, a local tool was developed which integrates evidence based normative data and functional swallowing measures to meet the needs of the EH SP department.

Conclusions:
A VFSS interpretation tool has been developed and implemented at EH which is evidence based and patient centred with a focus on function rather than impairment which also meets the needs of the SP department.

Keywords: Videofluoroscopic Swallowing Study, rating, interpretation, dysphagia, functional measures, impairment measures.

Submission statement: Responding to changes in evidence based practice and feedback from the Eastern Health Speech Pathology department led to the development of a videofluoroscopic swallowing study (VFSS) interpretation tool which integrates evidence based normative data to highlight functional swallowing measures and meets the needs of the speech pathology department.

Introduction: Pre-swallow pooling is a feature of dysphagia caused by poor bolus containment (a motor impairment) or delayed pharyngeal swallowing (a sensory impairment). However, differentiating between them is difficult. This leads to risk of inaccurate diagnosis and treatment, and inability to accurately measure change following rehabilitation or make comparisons between research studies.
Aims: We present a scoping review on terminology to describe pre-swallow pooling, the methods of measurement, and features that differentiate this sign into underlying causes of poor bolus containment or delayed pharyngeal swallowing.
Methods: Online databases were accessed to identify publications that used a term to describe pre-swallow pooling. We searched Medline, CINAHL, EMBASE and EMCARE with search terms relating to hesitation of the bolus in the pharynx prior to onset of pharyngeal swallowing.
Results: There were 850 papers extracted for review. After removal of duplicates and application of inclusion criteria, 140 articles remained for analysis. There were 235 unique terms used to describe pre-swallow pooling; 92.1% (129/140) articles used the term as an outcome measure; 65.9% (85/129) provided a method of measurement of which 15.3% (13/85) were specific enough to be replicable. Of studies which did acknowledge a difference between poor bolus containment and delay (29/129; 22.5%), only 24.1% (7/29) described how to differentiate between them.
Conclusions: This review suggests the need to increase consistency in terminology and measurement of pre-swallow pooling. Development of measurement methods to accurately differentiate poor bolus containment from delayed pharyngeal swallowing is required to further our knowledge on this pathophysiologic feature of dysphagia.
Key Words: Deglutition; dysphagia; pre-swallow pooling; delayed swallow; poor bolus containment

Introduction
This study explores the implementation of Speech Pathology Australia ‘Informed Choice and Shared Decision Making with Individuals who Eat and Drink with Acknowledged Risk (EDAR) guidelines (SPA, 2021) at a public and private health care facility in Perth, Australia.

Aim(s)
The aim of this study was to explore the current clinical approaches to shared decision-making, and the facilitators and barriers perceived by speech pathologists in the implementation of these guidelines for adult patients with dysphagia within a public and private health care facility in Perth, Australia.

Methods
A qualitative research design was implemented to explore Speech Pathologist's experiences with shared decision-making with clients who eat and drink with acknowledged risk through an online survey with follow-up semi-structured interviews. Ten survey responses informed the semi-structured interviews of six participants. Interview data were analysed using reflexive thematic analysis.

Results
Findings were mapped against an appropriate framework for guideline implementation. Collectively, Speech Pathologists found implementing the EDAR guidelines (SPA, 2021) challenging, due to the complex nature of shared decision-making, the lack of consensus for defining when a client is eating and drinking with informed risk, and a power imbalance between medical staff for decision-making.

Conclusions
This is the first known study to explore the implementation processes of the EDAR guidelines (SPA, 2021) acknowledging the complex context of shared decision-making working with adult patients with dysphagia. The presentation will explore facilitators and barriers to practice guideline implementation which may assist other speech pathology services

Introduction: Evidence on dysphagia in COVID-19 is limited with outcomes mainly reporting prevalence and recovery data. Much less is known about the biomechanics of dysphagia in COVID-19 which is critical to rehabilitation.

Aim(s): To define the physiological profile of dysphagia in the COVID-19 patient using Flexible Endoscopic Evaluation of Swallowing (FEES).

Methods: A series of COVID-19 patients with dysphagia treated across two tertiary teaching hospitals (March 2020-March 2022), that underwent FEES as part of their swallowing management were recruited. Key physiological parameters were recorded from initial FEES using descriptive methods and validated outcome measures (FOIS, PAS, Yale, NZSS, Patterson-oedema-scale), to define the nature and severity of dysphagia. All footage was analysed by 2 experienced speech pathologists proficient in FEES interpretation with high inter-rater reliability established.

Results: 7 cases (5-male; mean age 64-years) with no pre-existing dysphagia were recruited. All cases required Intensive Care admission (mean ICU length-of-stay [LOS]=43 days, Hospital LOS=74 days). Mean duration of intubation was 27 days and mechanical ventilation was 35 days. 4 of the 7 cases required tracheostomy. On FEES, all cases demonstrated impairments in airway closure, tongue-base to posterior-pharyngeal-wall contact, pharyngeal stripping and laryngopharyngeal sensation with variable secretion management (NZSS=2-7), high rates of laryngeal penetration and aspiration on fluids (PAS=5-8) and greater vallecular (Yale=3-5) than piriform residue (Yale=2-4). Dysphonia and laryngeal pathology were observed in all cases.

Conclusions: Impaired airway closure, base-of-tongue drive and pharyngeal stripping was common across all COVID-19 cases. This evidence may guide rehabilitation to optimise swallowing outcomes in this challenging population.