Well, good afternoon, everyone. Welcome. Welcome to Baltimore. This is an all Baltimore crowd for you doing the presentations, so we're happy that you all are here to talk about dysphagia and discharge delays. Again, practical and ethical issues. I'm Dr. Marlise Gonzalez-Fernandez. I'm at Johns Hopkins where I'm Vice Chair for Cloned Collaborations. And I have a great set of collaborators here who are at the University of Maryland and will be talking to you about these topics. But before we get started with the formal program, let's just try to warm up the audience. I have a few numbers here, 500 to 700. Then a dysphagia talk. You guys want to, anyone wants to take a wild guess what this is? 500 to 700. That is the number of times we all swallow in a day. So just to give you some perspective, today is October and next is coming Thanksgiving, right? I tried to find the picture that was most emblematic of Thanksgiving in the US. So you can imagine if you're walking into this room how this house smells, right? The smell of the food. And if it's not turkey for you, think of your favorite ethnic food and then think that eating this meal is very difficult for nine million people in the United States who have a swallowing problem. And that's the kind of thing that while we're here today, when we talk then about people not being able to swallow in the US, we're talking about 300,000 to 700,000 people of which we can generally estimate about half have dysphagia due to stroke. So that's why we're here today. And I'll leave with you a little bit of these problems. So if, let's see how we can make this work. Oh, there you go. So when people that problem swallowing, this is swallowing liquids and there's lots of physiologic problem but look where this liquid's gonna go. Right there in the trachea, you see the cough. Most people are not as obvious as this when they have a swallowing problem. So we need some nuance. We need to do some evaluations and this is a modified barium swallow or a video fluoroscopic swallowing study. That's where we see what's happening. So that's my plug for testing. And without further ado, I'll let you know our learning objectives. First, again, we'll start to identify common deviations from the established practice, from the clinical practice guidelines that are available to treat post-stroke dysphagia. We want you to be familiar with the American Heart Association guidelines in this case and then understand factors that influence dysphagia prognosis and choices for dysphagia therapy. That's why we're here today. And Dr. Braun, I always say that wrong. Did I succeed? You did. Awesome. Will talk to us about a study that was conducted at University of Maryland looking at this issue. Robyn. Thank you, Marlise. So as we just discussed and as we all already know from our clinical experience, dysphagia is a very common problem after stroke. But the question is how common is it really? And I put a quote up here directly from the 2019 AHA guidelines which states that dysphagia is a common problem that occurs in between 37 and 78% of strokes. And my question is why is this range so large? And the reason for that is because there's a great deal of variation both in the method of assessment that we're using to determine the presence or absence of dysphagia and also it's a dynamic process. So depending on when you evaluate for the presence of dysphagia is gonna determine how frequently you think it occurs. So this is really what led to the impetus for the current study that I'm gonna present as the first session this morning. And basically we started a series of discussions between PM&R and our speech language therapists to try and think about what were some of the common observed practice patterns in our center? And also what were some of the issues that we were seeing with common practice patterns? So for one thing in a discussion I had with my colleague Jody Arado, who's one of our excellent speech language therapists, we found that patients were coming to our rehab center with pegs and then advancing to an oral diet very shortly thereafter within the order of about a week. We also found that the different types of assessments that were being done for swallow evaluations at our downtown medical center were inconsistent. Some were instrumented, some were not. And so in 2018 Jody and her student set out to do a preliminary analysis for us to see how well our practice patterns were aligning with existing guidelines. So of course to see how well we're doing we gotta know what those guidelines are and I'm just gonna touch briefly here on the dysphagia and nutrition guidelines for the 2019 AHA RECs. So starting with dysphagia, there's some pretty general recommendations. Dysphagia screening is recommended. Endoscopic evaluation is reasonable. There's some ambiguity in the RECs regarding whether that dysphagia screening can be performed just by a speech language pathologist or by another trained healthcare provider. Also a little ambiguous as to which instrument should be chosen for that instrumented evaluation. So consider as topics for future research directions. But these are what the recommendations were as of 2019. They also notice, I think we know very well as rehab physicians, that implementing oral hygiene's protocols is very important for preventing aspiration pneumonia. And then this is the part where I think the recommendations get a little more interesting and I really wanna focus in on item two here which says that for patients with dysphagia it's reasonable to initially use a nasogastric tube for feeding in the early phase and to only place a percutaneous gastrostomy tube for patients who have a longer anticipated persistent inability to swallow safely. So that being, we start thinking about that decision around two to three weeks after stroke. So I wanted to kind of give you guys a little road map of the evidence that was used to generate those AHA guidelines. So to start with, there was this study in 2000, or excuse me, actually in 1987, a classic study by Gordon which showed that dysphagia post-stroke lasted an average of 8.5 days and actually 86% of patients with initial dysphagia were swallowing normally two weeks later. Then the second item here is the FOOD trial which was a 15 countrywide study in 2005 which again stated that the first two to three weeks of ventral feeding should be by NG tube as the chosen route. And then lastly, some later recommendations from Dennis and colleagues in 2016, again reiterated that if ventral feeding is likely to be needed for longer, in other words for more than 28 days, a PEG should be placed within a stable clinical phase after 14 to 28 days. So a little bit later in the time course than we had been seeing this happen. In addition to these kind of practical considerations, there's also a big ethical dimension to this because you have to remember as clinicians, patients and caregivers, we really struggle sometimes with weighing the risks and benefits and quality of life considerations around these enteral access decisions. And this paper from Ruben and colleagues had stated that actually 50% of seriously ill hospitalized patients reviewed relying on a feeding tube to live as being equal to or worse than death. So this is pretty major statement about the importance of eating by mouth as an oral intake and a quality of life issue. When we're talking with our patients, we then have to weigh these kind of moral and personal decisions against the very real risk in morbidity and mortality associated with dysphagia. So dysphagia is associated with a threefold increase in mortality. About 50% of those with dysphagia will aspirate. 33% of those who aspirate will develop pneumonia. And of course, there's an increased predicted risk of death at three months with that pneumonia diagnosis. So we really have to kind of stride a delicate line between the ethical considerations, the very practical considerations for the health and well-being of our patients. So looking at a very sort of broad swath of common practice patterns in this 2017 study by George and colleagues, with a large N in 34,000 patients across 1,400 hospitals, they assessed and found that the mean time to PEG placement was about seven and a half days. So this is clearly much earlier than that recommended kind of two to three week time frame that we saw discussed on the previous slide. The median rate of early PEG placement, which by here they mean PEG placement in the first one to seven days, was in more than half of patients. 56.4% of patients were getting those PEGs within the first seven days. So these authors, again, really remark on this mismatch between practice and guidelines in terms of the early placement of these PEG tubes. How does our personal practice at University of Maryland stack up against this is what we then wanted to know. So in 2018, my colleague Jodi Arata and her student did a little preliminary analysis on just a small sample of patients to see how many patients were recovering SWALA within the first seven days of arrival to our rehab unit. And in that preliminary review, she found that most of the cases were recovering PEG, were receiving their PEG at an average of 11.4 days. So that's a little bit better than the 7.5 days that we saw previously. But it's certainly not as good as we might hope. The average number of days from that PEG tube placement to the initiation of an oral diet was 7.35 days. So patients were getting a PEG and about a week later, their SWALA was recovering. So again, that makes this question, were we really moving to PEG too early here? And then the average number of days from onset of the stroke to initiation of a PO diet was 24 days. So this led us to consider that if we had allowed these patients up to 28 days with nutrition via an NG tube, as the recommendations had suggested, we could have really prevented some unnecessary surgical procedures. So in 2019, we underset to take a new programmatic development, which was an initiative between PMNR and speech therapy and our executive leadership to accept stroke patients to our rehab hospital with nasogastric tubes. And this is not something that had been a practice pattern at our site previously, nor is it done by many of the other inpatient rehabilitation facilities in the area, especially our subacute rehab skilled nursing facilities are very wary of taking patients with NG tubes. So we wanted to see how that might work for us at our site. So we gave the program a couple of years to play out. And in 2021, we felt that we had some pretty good data to start working with. And I actually had a neurology resident who was interested in the program and worked with me, Ken Han, on a collaboration to ask the question, can a PMNR consultation effectively identify patients who will recover their swallow function during their rehab stay and possibly should be accepted with an NG tube. This was kind of cool because we had both the acute neurology side with our neurology resident and the PMNR side really kind of joining hands to work on this. And so we looked at the current practice patterns for PEG placement post-stroke in a larger sample of our patients that were admitted from University of Maryland Medical Center to our UM Rehab Hospital. And we wanted to assess the outcomes of patients that were selected for admission with an NG tube versus those who were selected for admission with a PEG by our PMNR consults team to see if they followed the predicted course of dysphagia recovery. It's important to point out here that we could incur a selection bias in this sample because of the fact that we were looking at only the patients that came to our UM Rehab inpatient rehab hospital. However, it's important to note that, I wanted to give you a little context on what UM Rehab is like to help in your interpretation of the findings. UM Rehab is a standalone rehab hospital. It's a large hospital where we have four units among which one of is a 35 bed stroke rehab unit. That is where all the patients who were assessed for this study were admitted. And this being Maryland, we have a rehab designation that's called the quote unquote chronic designation which means we can accept a limited number of patients who are more medically complex but do not yet meet the three hours of rehab therapy a day requirement. So in this case, it actually helps us a little bit because with the generalizability of our results, we actually had a broader swath of patients in this study than you might see with your typical kind of cream of the crop acute rehab candidates. The cases that we assessed, again, this was a single center retrospective study. These were admissions between 2019 and 21. We had 426 patients with a history of dysphagia admitted to our rehab hospital from our University Medical Center. And of those, 121 had persistent dysphagia at the time of their rehab transfer. Three to five of those had recovered actually by the time that they transferred to rehab. Our PM&R consult team did approve 44 of those for transfer with an NG tube. And the other 75 patients had PEG tubes and were approved to come to rehab with that. We did exclude two patients on the basis of non-neurologic factors that were affecting their PO status, such as GI bleed. And what criteria did the PM&R team use to kind of assess the candidacy of these patients to come with the NG tube? So some of you may be familiar with the study that came out in JAMA in 2019 called the PRESS study or PRESS score. That study was conducted among five centers in Switzerland. And although it was a good study, we felt it was a little bit early still to adopt those guidelines wholly into practice at our site. So we did incorporate some elements of the PRESS score, including age, which has consistently been associated with poor swallow recovery. We assessed stroke severity. And we assessed the presence of unilateral versus bilateral stroke. And that all overlaps with PRESS. However, we also considered many other factors. So importantly, whether there was the presence of a pharyngeal component to the dysphagia, or was it only oral in terms of the stroke location? Was there frontal lobe involvement that could affect the patient's kind of overall level of consciousness or cognitive ability to benefit from the therapy? Or was there brainstem involvement that would directly affect those cranial nerves involved in swallowing? We also look at whether the patients are able to follow commands for orofacial and lingual movements. And this is the kicker for the PM&R folks is we really think about the anticipated rehab length of stay as well. So we can't necessarily make this decision just on the basis of the speech therapy eval, which is an essential component of our decision making. But we also have to think, is this a person who's gonna recover from their dysphagia? And also, is that gonna happen while they're doing their rehab stay? Or are we gonna end up getting stuck at the end of the rehab length of stay with someone who now needs a PEG and has to go back to the acute hospital and get that before we can do anything else? So that kind of joint decision making between PM&R and our speech therapist is really important. In terms of the baseline characteristics in our sample, there were no significant between groups differences in terms of gender, race, or age for our patients that were admitted with NG tube versus PEG. And also the groups did not differ significantly on the basis of their stroke laterality, type, location, or severity. In terms of the time that it took for patients to recover their swallow in these two groups, there was a significant difference where the patients with NG tube recovered their swallow in a mean of 20.37 days as compared to the PEG group who recovered their swallow almost two weeks later at 34.46 days. And that difference was significant at the P less than .001 level. So how good are we really at making the call on these cases? So what I've plotted here is the relative proportions of patients who recovered their swallow that came with NG tubes or came with PEGs scaled to 100% of the sample. And what you can see from this is, for those accepted with NG tubes, our true positives were 38. That is, we thought they were gonna recover their swallow and they did. There were six false positives, so some of those patients with NG tubes did not recover their swallow, but still 38 out of 44, that was 86%, who actually did recover. In terms of the patients who were accepted with the PEGs, our true negatives were 46. However, there were still 29 that were false negatives, so we didn't think they were gonna recover, but they did. So this gives us basically a pretty high specificity here, of 0.89. We had relatively few false positives, so that means there was a pretty low risk that patients coming with NG tubes were gonna get stuck at rehab with that NG tube. On the other hand, unfortunately, there's also pretty low sensitivity here. So we had a relatively high number of false negatives, and that means that there was a relatively high risk of these patients getting unnecessary PEGs. In terms of the decision making on this, the patients who came with the NG tube, basically, this was a call that rested squarely on the shoulders of PMNR. We were the only consultants who would have approved the patients to come with the NG tubes. They had to do not pass go, they had to go through us before they would be admitted in that kind of track. On the other hand, the decisions around placing the PEGs or not placing the PEGs, that's something that was really shared decision making that more fell on the part of the acute neurology teams. So we don't necessarily have as much of a role in that aspect of the decision making. So what about length of stay for these folks? So there was a significant difference in the acute hospital length of stay of 12.9 versus 20.4 days. and you might wonder, does this also affect the rehab length of stay? Because if we're taking those patients with NG tube sooner, are they just kind of coming to rehab and loitering around longer until their swallow recovers? But no, in fact, there was no significant difference in the rehab length of stay, which was 26.9 versus 32 days. So there was no kind of proportional increase in length of stay for the patients coming with that NG tube. And we can't necessarily take all the credit for this, as the PM&R consulting team saying that we just move these patients more efficiently. That's probably part of the story, but we do also have to consider that the patients who were coming with PEGs could have come as part of that trach and PEG kind of combo maneuver, where these were already complex patients that obviously had complex respiratory involvement, and therefore, they were just gonna have a longer length of stay regardless. So limitations for this study, obviously, it's a single center study, retrospective study, limited population of IRF patients with persistent dysphagia. Our chart abstractors were not blinded to group composition. Our sample is geographically limited. And we only had longitudinal data available for our patients who were coming to UM Rehab. I already mentioned there's potential bias here with the single site acute rehab hospital. But as I mentioned, because we accept chronic patients as well, that hopefully is ameliorated to some extent. But these are things just to bear in mind when interpreting our findings. So in terms of my takeaways, physiatrists are often consulted to facilitate hospital throughput and reduce length of stay in the acute hospital. It's one of our most common consults, right? And in fact, PM&R BOLD really emphasizes our physiatrists' expertise in managing utilization of resources across the continuum of care. So I would argue that a great place where we can make a major contribution in this is the complex decision making around enteral access options. I would argue that physiatrists-led initiatives like the one we presented here can improve patient and family discussions about dysphagia prognosis and rehab goals. They also contribute much needed longitudinal data on dysphagia recovery, which is still really a gap in a nascent body of literature. And what am I pleased to you all is to start thinking about tracking these outcomes at your sites because we really need this longitudinal data and rehab is the side of the fence that is missing from this story. And lastly, we think that these consultations can also potentially expedite transitions and reduce length of stay in the acute rehab hospital. So some things to think about. And with that, I will pass the baton to my colleague, Dr. Gaurab, who's gonna talk about some of the administrative aspects of actually implementing this program. Thank you. Thank you, Dr. Braun. Thank you. Thank you, Dr. Braun. I'm Krishnath, I'm the Chief Medical Officer of University of Maryland Rehab and Orthopedic Institute. As Dr. Braun mentioned, we are a freestanding rehab hospital within the University of Maryland medical system. Close academic collaborations with Johns Hopkins and other rehab providers in the area. I'm going to talk a little bit about the implementation and the change management part. What Dr. Braun explained was that our previous state that we will not take patients with NG tube. We are currently at a state that we will take patients with NG tube because this is best for the patient. This is adherence to best practice guidelines. So what allowed us to make this change? So I'm going to talk about that aspect. I don't have any disclosures. I wish I had many disclosures. I do not have any. I am a physiatrist. We have an interactive audience response system. So if you could point your, yeah. Point your mobile devices and scan this QR code, you'll be able to, we will be able to record your answers. Unfortunately, we can't display the answers in real time. So I will ask Dr. Braun to help me out over here. Okay, let's go on to the first question. What is the average length of stay of patients with stroke in acute care hospitals in the United States? Not in Netherlands, in the United States. Few seconds to respond. Okay, we have the audience response in and the graph is stabilizing at, in the acute care hospital, 47% or 45% of the attendees over here believe that it's between 11 and 14 days for stroke patients. 30% believe it's six to 10 days. 14% believe three to five days. 11% believe greater than 14 days. For all the 11% who said 14 days, be the power with you, but unfortunately, it's not true. I wish it was true, but it's not. Let's move on. Coming back to, that was like the environmental scan question coming back to a single patient, right? We'll give you the answer. We'll give you the answer. Sorry, that's a suspect. We'll give you the answer. So let's come to an individual patient level. And this is a patient that we took care of, 36-year-old female, and Jodi Arad, our speech therapist, will give you more details, but she had a left-sided CVA. Number of days from CVA to PEG had a stroke, and we put the PEG tube in, or the acute care hospital put the PEG tube in, was 10 days. The question is, and don't answer it yet. I will tell you when to answer. The question that we'll have to ponder about is this. The PEG placement was performed at an appropriate time. Do you agree with this statement? Yes, no, or we don't know, need more information. Don't answer yet, hold on. Let me give you some more information. First piece of information, if you were, what Dr. Braun mentioned, the best practice guidelines food trial, large trial, right, thousands of patients, said that if enteral feeding is needed in the first two to three weeks, nasogastric feeding should be chosen unless there is a strong practical reason to choose PEG feeding. And the example that the authors provide in the study was that if the patient cannot tolerate the NG tube. So that is the best practice guidelines. On the flip side, if I want this patient to stay in the acute care hospital for about two to three weeks to see whether we really need a PEG tube or not, that will increase the length of stay in the acute care hospital. And that's not only an operational consideration. I mean, think of a tertiary acute care hospital. If there's a patient who is just waiting for solid recovery to happen, maybe that bed is better utilized for somebody who just had an acute stroke. So it's not only an operational consideration, length of stay is also a patient care consideration when you have limited beds. And of course, let's say she was eligible for, otherwise eligible for a go to acute inpatient rehab, just waiting for two or three weeks in an acute care hospital and not getting the multidisciplinary therapy, it's probably not best for her. So that is the counterpoint, right, that we should immediately put the, we should put the PEG in early and send her to a rehab facility. Here is the answer. What is the acute length of stay we are managing to in the acute care hospitals? This is old data because that's what has been published till now. It's around six days. Patients who enter the hospital through the ED to the ICU stay longer. Patients who don't end up in the ICU stay a shorter amount of time. But that's the average length of stay for stroke patients in the US acute care hospitals, around six days. You might say that okay, maybe let's take the middle path. Let's bring the patient in the acute care hospital, swallow has not recovered, let's discharge the patient to another facility or home and bring the patient back. We all know, all of us who are working in the inpatient setting know that it's extremely challenging. At least in our area, there are not many rehab facilities who will accept a patient with a NG tube with an estimated prolonged length of dysphagia as happens after stroke because they are scared that they would get stuck with the patient. Theoretically, it's possible to discharge somebody home with a NG tube, but how many times we find families who are so resourceful that they will take care of the NG tube, the feeding, managing the residuals, bring them back for speech therapy or have speech therapy at home daily and then bring back for a PEG tube. Almost never happens practically. So that's often not an option that's available to our patients. Now is the time, when I've given you both the pros and cons of an early versus late PEG, please answer this question. For this lady, 36-year-old lady, PEG tube was inserted at day 10. Do you agree that this was an appropriate time to enter the PEG tube? Yes, no, or we don't know, need more information. Just give a few seconds for the numbers to stabilize over here. Okay. 18% say, hmm, still moving, but anyway. Around 15% say that it's okay, PEG tube was inserted at an appropriate time. 64% say that, no, we should have probably waited. Around 20% say, don't know, we need more information to decide, right? So while you were making these choices, you were probably weighing these options. The options that you were weighing were to wait about two to three weeks before converting from a nasogastric tube to a PEG tube because that is what, as Dr. Braun mentioned, the best practice recommendation, and therefore prevent an invasive procedure which is not readily reversible, right? We cannot take out the PEG tube. Let's say after 10 days, the swallow has recovered, we cannot pull out the PEG tube. We have to wait for the tract to form. And sometimes it comes as a surprise to patients and their family members. Why can't I take out the PEG tube? It's not as simple as an NG tube, right? Or you might be considering that let's put the PEG tube early and facilitate the discharge and patient is appropriate inpatient rehab, goes there, gets great rehab and goes home. Those were the options, right? As healthcare providers, we should not ask our patients or their family or their loved ones to make this decision. It should not be an or question, it should be an and question. And it's our job about how do we go from or to and. That is, we adhere to the best practice recommendations that we should wait for a PEG tube for two to three weeks before we make that decision. And while doing that, we facilitate discharge and if the patient is ready for acute rehab or other kind of rehab, send them to rehab so that they can get the benefit of both. And that is the change that we were tasked to do and we did. And that required change both at the acute care hospital and at our inpatient rehab facility. In the acute care hospital, we had to educate and convince the primary teams not to put in PEG tubes prematurely in stroke patients. In the inpatient rehab facility, we had to convince our rehab providers to accept stroke patients with nasogastric tubes. And since I'm talking about change over here, here is another question. In your practice, either as a clinician or an administrator, can you name one change management principle that you have used? You can name anything. It can be anything. It can be completely made up. So I'll just wait for a few seconds. Name a change management principle. Create a burning platform, yep. Scarf, I do not know about that. Maybe we can discuss later. Lead by example, communication, education. All great answers. Okay, they're still coming in. Identify early adopters. Yes, change management model. Okay, we have got some great examples, so. Keep them coming too. Keep them coming, keep them coming. This is awesome, thank you. This is awesome. Yeah, very helpful. Okay, just I'll give you two examples. One that we frequently use. This is familiar to many of us. Carter's Eight Steps for Leading Change. Starts with creating urgency. Somebody said create a burning platform. Similar to that, creating an urgency. And then finally, making changes stick. I would not go through all of these, but as I go through the subsequent slides, hopefully you will find reflections in some of these change management steps as we implemented our program. Another example, Levin's Theory of Planned Change. The only thing I would point out over here is that see where is communication. It's present in all states. Right from where we identify what needs to change and when we have reached to a stable state, communication is extremely important. Later, in later slides, you will see why it is so important. In my practice, I have often found it helpful to start with a why. As healthcare providers, especially physiatrists, if we start with a why, we should do this because this is what is best for our patients. It really motivates everybody around us. This is why we should do it. And then we can figure out how do we do it and what exactly we do. So for us, it was that we are not adhering to best practice guidelines for dysphagia recovery in stroke. How can we figure this out for our patients? That was our urgency and our goal. And this is the team we assembled to make that change happen. In the acute care hospital, our frontline staff, nothing, we should not make any changes without consulting our frontline staff. They are the boots on the ground. They absolutely, we have to listen to them. This is in the acute care hospital from our frontline staff and executive leadership. Inpatient rehab facility, again, our frontline staff and our executive leadership. When we ask the frontline staff, what are the barriers for accepting patients with nasogastric tube to our inpatient rehab facility? These are the three more common, three common themes that came out. They cannot do three hours of therapy with a nasogastric tube sticking out of their nose. It often falls out, creates lots of disruption. If a PEG is needed, finding a facility and appointment is difficult and delays discharge. So therefore, the patient will be stuck with us, will not take them. And sometimes, and I'm sure it's happened to all of us, we go back and tell the patient that, hey, your swallow is not recovering. We will have to put a PEG tube. And they would say, what? Nobody told me about this before. And then that's the apprehension from the rehab doc's point of view, that we are telling the patient, the family, that there will be a hole in the stomach and we'll feed through that, right? So these were the things that we listened from, that came through our frontline staff. How do we remove these obstacles? Nasogastric tube falls out during therapy. We requested our primary teams that whenever possible, nasogastric tubes should be secured, not possible in every patient, before transfer to inpatient rehab facility. And we also requested the primary teams to have a discussion with the patient and family and document in the chart that if the swallow has not recovered, they might need a PEG tube. The third thing, that if a PEG is needed, finding a facility and appointment is difficult and delays discharge, that was probably the most difficult to solve. And we had three options. What we gravitated to is the last option. That, okay, send us your patient. That is, we told the acute care team, send us your patient. But should this patient need a PEG tube, please give us an appointment within the first, within one week, so that we are not stuck about trying to find an appointment. And the reason we did this is that, and the reason we did not choose the first one is that, as Dr. Braun mentioned, we are an acute care, we also have, we are a freestanding rehab facility, we also have ORs. There was a thought that we should create an OR just to put in PEG tubes, but we are part of a larger system and many of you may be working in larger systems. We should not be duplicating resources at every place. We should try to find resources across the continuum so that we can do it in a very value-based way. So that's why we chose the third option. What are the results? We now routinely accept stroke patients and as Dr. Braun mentioned, we have excellent results with them. We are adhering to the best practice guidelines and we are getting patients rehab when they actually need the rehab. We did this in 2019, 2020, and after that, everything was okay, right? It does not happen in rehab, does not happen in healthcare, right? So this is the email from about three weeks back. We took a patient, patient needs PEG, we asked the acute care hospital that, okay, give us an appointment. Okay, you have an appointment four weeks from now, right? And making changes stick is difficult in healthcare because there is change in personnel, people forget, especially for an event that doesn't happen that frequently. We should be comfortable with that. We should not get frustrated with that because making changes stick is the most difficult part. And this is why. Our entire initiative is based on education. Whenever we have an initiative or a change based entirely on education, the compliance goes up. But if you don't keep reinforcing, the compliance goes down and down and down. We have to keep on reinforcing. Again, we should not get frustrated because of this. This is just natural course. Unless we hardware this change. Take home points. Evidence-based recommendations for timing and PEG placement. Oh, sorry. Evidence-based recommendations for timing of PEG placement in stroke patients versus expectations of managing acute length of stay may be at odds to each other. Leveraging system resources across the continuum of care may be a potential solution. That's what we did. We found a solution across our continuum of care. And we should, even as clinicians, we should try to use change management models which have been proven to work when implementing changes in the clinical practice for the betterment of our patients. And if we are using only education as a change management, this is what happens. We should expect some amount of drift. So expect drift when education alone is relied upon to sustain change. That's all I had. Thank you for your time. I will pass on the mic to Jodi Arata on one of our very qualified speech therapists. She will talk about the magic that happens in speech therapy so that our patients actually recover their swallow function. Thank you. I can't believe you're wearing something like that. All right, so thank you, Dr. Garab, for the introduction. So for session three, we're going to talk a little bit more about the therapist, patient, and caregiver perspectives on dysphagia recovery, including prognosis and therapy approaches. All right, so within our department at the University of Maryland Rehab, we, sort of the speech team, started to re-examine our own approaches and practices with regard to recovery and therapy prognosis after a stroke, and tried to look at how did our therapy and diagnostic approaches align with the extant research and data. And during this time, with the assistance of my student intern, Jillian Jones, we started to look for answers to questions such as what is the timeframe for patient-level dysphagia recovery after a stroke, the timeframe for PEG tube placement, and what are the indicators for placing an NG versus a PEG. All right, and then in reviewing the literature, what we began to see was that there were some pretty big challenges in predicting dysphagia recovery after a stroke, including some major inconsistencies in the literature about how dysphagia was being diagnosed to begin with. So we're coming at the literature, and we're seeing that some papers are saying, you know, they were diagnosed with dysphagia based on a nurse screening. Others are saying they're basing it on a clinical or a bedside swallow eval, while still others are using fees or MBS and instrumental assessment to diagnose dysphagia. There's also very limited research in general. We've kind of touched on that a bit so far. So namely, we wanted to look at how is dysphagia actually diagnosed, how and why therapist recommendations were made, and what is constituting recovery. All right, so briefly, just to talk a little bit to the swallow screening by RNs. That is typically a three ounce or a Yale swallow protocol, which is typically a great way to screen for dysphagia risk, but it is not intended to diagnose. So appropriate tool to see is there risk, do we need to do an instrumental assessment, but really not an appropriate tool to be saying this person has dysphagia, but that is cited in a lot of the research as the diagnostic criteria. With this use, we see, sorry, that's okay, thanks, all right, so use of this screening method resulted in, results in over restriction for liquids for up to 50% of patients tested using this method, and up to 71% of patients who do fail the swallow screening are actually able to safely intake food and liquid using some modality, whether that's altering consistencies, altering delivery methods, or presenting food and liquids in a different way, they are able to intake something. So if you're just saying they failed, they have dysphagia, moving on, gonna peg them, whatever it may be, you're missing a lot of pieces of the puzzle there. All right, and then with the bedside swallow eval, this is kind of, this one you see a lot more often in the literature, but unfortunately, you know, it consists of sometimes things like laryngeal palpation, listening for breath sounds, trialing different consistencies of food and liquid, and unfortunately, those things are not actually shown in the literature to be very effective. This is, you know, it's typically conducted by an SLP, but even so, for example, immediate vital sign changes when somebody is eating or drinking, not held up by the literature as effective at diagnosing aspiration, and up to 40% of the strategies that are used by speech pathologists in doing their clinical swallow evals are also not supported by data and have poor inter and intrajudge reliability. All right, so then of course we have our instrumental assessment, which is the gold standard for our field, and the only way that we can visualize the oral and pharyngeal stages of the swallow, and really diagnose pathophysiology. Unfortunately, here, there's also some really poor standardization of these approaches. An exception is the MBS-IMP, which is a standardized protocol for MBSs, but very many people are not trained in it, or they don't use it consistently, and it is an expensive course to take. Most places don't just give it to you, so it, you know, only goes so far, and currently, there was a recent literature review where, in 2018, a survey was conducted with 303 practicing SLPs in dysphagia management, and they were provided with three separate MBS studies, and they were supposed to identify the primary physiological impairments. One of the studies was easy, one was moderate difficulty, and one was complex. For the easy swallow study, only 67% of SLPs were able to identify the actual impairments. For the moderate and complex studies, it was even worse, it was 6%. So that's pretty abysmal, so if this is how we're diagnosing dysphagia, in order to write these research papers and look at these longitudinal studies, we've got to really question how we're diagnosing it to begin with. This accuracy does rise to about 81% for people who use frame-by-frame analysis, which was enabled during the study, however, that's something SLPs are not often allotted time for the completion of, or documentation of. So they were given MBSs to review, so they were... No, no, no, no, it was not. All right, all right, and then, so I'm just going to dive in, so at the time, in 2018, when I was working with my student intern on the literature review, there was only one systematic review of the literature on dysphagia recovery after a stroke, and unfortunately, this paper used PEG tube removal as a proxy for recovery, which is problematic because it omits those with NG tubes, those for whom a PO diet has been initiated but the PEG hasn't been removed, and of course, those for whom there are barriers to PEG tube removal, like access to somewhere to go for it. The review of the literature, this review of the literature found only one positive prognostic indicator that was identified in more than one study, which was a whopping two studies, that said absence of aspiration on an MBS was a positive indicator. There were additional indicators that were not replicated across studies. Those are listed there, but one in particular kind of exemplifies some of the problems in research and diagnostics that we've been talking about, and that is timely initiation of the pharyngeal swallow. This indicator was identified by Yee and colleagues in 2012 paper, however, the authors do not define how they measured timely initiation of pharyngeal swallow. There's no mention of timing measurements. There's no mention of any of the software used or how they did it is just unclear. So it could just be their gut feeling. All right, and then more recently, there has been a systematic review of the literature for stroke and dysphagia prognosis that was completed, just published in 2022. It defines recovery a lot more broadly, including standardized measurements, upgrade to oral diet, and discontinuation of enteral feeding. This review actually did find some of these predictors that were replicated across studies, including higher age, presence of airway compromise, which could be either aspiration or penetration in this sense, higher dysphagia severity, presence of bilateral lesions, and higher stroke severity typically measured with the NIHSS. Notably, the findings from this most recent review also have some overlap with the PRESS score that Dr. Braun mentioned earlier, including frequent use of the FOIS, which is the functional oral intake scale, NIHSS scores, and older age as predictors of persistent dysphagia. And I'm gonna very briefly, let's see, all right, so this may be an important slide to pay attention to. This may come back up. So if we look at those two literature reviews, the positive recovery indicators were younger age and absence of aspiration on an instrumental assessment. The negative recovery indicators were airway compromise, including penetration, higher dysphagia severity, presence of bilateral lesions, and higher stroke severity. I'm gonna briefly touch on this. You've already heard it from Drs. Braun and Garab, and you know, literature had a lot of limitations too in looking at PEG-2 versus NG-2 and the guidelines for that, similar diagnostic problems, but generally, as we discussed, we are looking at recommendations for PEG-2 placement in about two to four weeks after a stroke. All right, and then Dr. Braun already touched on this, that my student and I used this literature about PEG and stroke recovery to compare with a small sample of 10 patients. I'm not gonna re-present the findings, but suffice to say, if they had been given, you know, 18 to 28 days for recovery, these people may have avoided placement of a PEG-2 altogether. All right, so this review of the evidence on prognosis for post-stroke dysphagia recovery and on timeframes for PEG-2 removal, or PEG-2 placement, resulted in some programmatic changes at UM Rehab and at University of Maryland Medical Center, as we've discussed. The biggest change, of course, being our acceptance of stroke patients with NG-2s to our rehab hospital, but it also resulted in some changes within our practices as SLPs, and that was across the system, so talking about being a little more standardized in our approaches to MBSs, we really started to have a dialogue between the acute therapist and the rehab therapist about what do we need to see, you know, what kind of, you know, what consistencies, what volumes, how many trials you're doing, like, these things need to be outlined explicitly so that we actually know what we're looking at, and not just seeing aspiration, yes, penetration, you know, and a diet recommendation, actually looking at the pathophysiology. All right, and then moving a little bit into, so just talking about the therapy background, now I want to talk a little bit about patient and caregiver perspectives. So patient self-determination is a big deal. It's often undervalued, despite being explicitly outlined by the Patient Self-Determination Act of 1990. Contributing to the devaluation of patient self-determination are the influence of time constraints for completing appropriate assessments and diagnostics and analysis, pervasive fear of aspiration pneumonia, like it's the boogeyman, and a hospital culture that looks at instrumental assessments through sort of a pass-fail diet prescription lens, and not as an actual diagnostic tool, as well as the emphasis in acute care on reducing the length of stay, as Dr. Harab said, six days, that's not a whole lot to actually really get in there and understand what's going on. So ideally, patients and caregivers, hospital staff, would be explicitly educated on the importance of instrumental assessment prior to pursuing PEG placement, the risks, the actual risks of aspiration pneumonia, and the risks associated with PEG placement, and the time required before a PEG can be removed, Dr. Harab touched on that, I've had so many patients come to me who say, I have to keep this in, like I can't, I'm done, I don't need it, let's pull it out, they don't realize that that's the case, that it has to stay in until the tract is healed. All right, so another factor that we need to take into account that is really important for dysphagia diagnosis and prognosis after a stroke is the pillars of aspiration pneumonia, which is by Dr. John Ashford, and the pillars of aspiration pneumonia are the three factors that have been found most consistently relevant in predicting the risk of a patient developing aspiration pneumonia. So likelihood, as you can kind of see in that pneumonia risk predictor chart, the predicted outcome is basically no pneumonia unless you have all three of these factors, so it's another important thing for therapists to be considering. So the first pillar of aspiration pneumonia is impaired health status as determined looking at the medical record, age, current diagnoses, lab values, and overall immune system function. The second is impaired airway protection, which is to be determined using an instrumental assessment only, not a screening by a nurse, and impaired oropharyngeal environment, so basically examine the oral cavity, how's the oral hygiene, that's your third pillar of aspiration pneumonia. All right, so we are gonna be getting to some case studies here, so get your computers, your phones ready. All right, we have to get the first, not yet, not yet, because we have one more to go. Okay. It's after this. Let me go over there. All right, so not yet, it'll be just in a minute, don't get too excited. So my first case study, this is a woman Dr. Graub mentioned earlier, I'm referring to her as Andrea. This case, so she had a left MCACBA, the age of 36, 10 days later she had a PEG tube placed, she was diagnosed based on two bedside swallow evaluations totaling just over 30 minutes, and when she received her MBS, which was when she came to us at UM Rehab, she had some oral dysphagia and no pharyngeal dysphagia at all. She also had zero pillars of aspiration pneumonia, and despite some expressive aphasia, her receptive language abilities were pretty intact. For her, PEG tube placement really led to some complications for therapy. She actually ended up having a ton of pain, and that prevented her from participation. She was refusing therapies due to the pain, and she had a lot of distress due to her aphasia and inability or difficulties communicating exactly what kind of pain she was feeling and what was happening to her. So she was very, very distressed about that. Her family was as well. They didn't really realize the complications that could arise. So if you take a look at this next slide, all right, so this is where you wanna kinda put your phones up and get in there. So I, you know, follow the QR code, and I want you guys to tell me what you think. How many of the risk factors did she have? What were her prognostic indicators? And let's see, what's going on here? Good prognostic indicators or bad? Just, there's both. Both are there. So just recovery indicators, yep. All right. Yep, yep. You guys are really hitting on it. So yes, I'm seeing, oh, it changed. Yeah, let's give it a second to stabilize here. Okay, so we've got, still unstable. All right, so about 32% of you identified younger age. I mean, she's 36. I think that's pretty young. Of course, 25% absence of aspiration on an instrumental assessment, accurate. 7% said presence of airway compromise on an instrumental assessment. But if you actually take a look up here, she had no penetration or aspiration on her instrumental assessment. Dysphagia severity, 11% said it was high. She had no pharyngeal dysphagia and only a oral dysphagia, so it was pretty low. She did not have bilateral lesions. She had just a unilateral left MCA. And her initial NIHS, yes, you could define that as higher. I think when we get to our next case, you'll think it's a little bit lower. But let's see. And then we have, there's another one too. Yes, right, we need to do the pillars of aspiration pneumonia, right? Yes. See if we can advance it. No pillars of aspiration pneumonia, sorry, that's it. Not sure. Going back. Sorry, no pillars of aspiration pneumonia. Let's assess that on case two. Yeah, all right, so some talking points. Some case one teaching points here. So the take-home points to consider for her include that yes, she did have two out of two positive prognostic indicators for dysphagia recovery, lower age, relatively lower NIHSS, and zero out of four negative indicators, no aspiration, no penetration, low dysphagia severity, and a unilateral lesion, and none of the pillars of aspiration pneumonia applied to her. Her PEG tube was not placed within the 14 to 28 day time frame we've discussed, it was only 10 days. She didn't have an instrumental assessment prior to the placement. Her MBS at UM Rehab was completed seven days after her PEG was placed, indicating only a mild moderate oral dysphagia, no pharyngeal dysphagia. A PO diet was initiated immediately of soft and bite-sized solas and thin liquids. And if we look at this, if she'd been given that 14 to 28 day window after her stroke, and received an instrumental prior even to her transferring to rehab, it's very likely she could have avoided a PEG tube altogether, and then we would have avoided the pain and distress that that also caused for her and her family. All right, so for the next case, this is a patient I'm calling Jeff, who was given an NG tube after he had a right MCA CVA, which was his second stroke. He was diagnosed based on three clinical swallow evals, totaling just over 60 minutes. His instrumental assessment was not completed during his acute stay. He had three pillars of aspiration pneumonia identified. He had moderate severe cognitive impairments, and in addition, he had a pretty recent history of hemiglossectomy and radiation. So for this guy with his NG tube, some of the treatment complications we ended up having were he needed bilateral mitts because he was trying to remove the tube, and that increased his agitation as he was, you know, his cognitive status was so impaired, and he had an inability to participate in our actual intensive dysphagia treatment because he couldn't follow the directions, the commands, the steps for participation. All right, so, with that there, let's talk about those, all right, so what about his prognostic indicators? What do you guys think? I don't think it's working. Ding, ding, ding. I wish you guys could see the chart, it's really cool. It would be great if you could. It is really cool. Just let it kind of stabilize here a little bit. So generally, you guys got it. He has airway compromise on his instrumental, high dysphagia severity, bilateral lesions, a high NIHSS score, 4% said absence of aspiration. He actually did aspirate on his MBS, but otherwise, yep, you guys kind of hit it right on the head. And then what about the pillars of aspiration pneumonia? Yeah, three out of three. You guys got it, unanimous here, all right. Thank you, Dr. Brown. All right, so some teaching points, some take home points to consider. You guys hit it on the head. He had none of the positive indicators for recovery. He had four out of four negative indicators. He had all three aspiration pneumonia risk factors. So overall, in a high risk category, someone who would likely need a PEG tube. He may have had an additional preexisting dysphagia due to the hemiglossectomy and radiation he received, may have been able to compensate for that prior, but with the second stroke, unable to do so. He came to us with the NG despite this kind of abundance of risk factors. And when he was with us, he ended up requiring three different MBS studies because his results were incredibly inconsistent, largely because he had poor, you know, all the studies noted for him, poor wakefulness, poor command following, inability to maintain a proper upright position during the test. So it was just very difficult for him to even participate in an instrumental assessment. He was unable to demonstrate comprehension of his results from his MBS or therapist recommendations due to his cognitive impairment, and had no caregiver who was nearby to take part in this. And continued to cough with PO intake, which of course triggers staff concerns whether or not it's relevant, and was dependent on staff for feeding, for oral care, and often he just refused to eat or drink altogether. So with this gentleman, a consideration of those prognostic indicators, the pillars of aspiration pneumonia, his medical history, and his cognitive function, along with completion of an instrumental assessment, would likely have led to maybe an early PEG placement for him. This might be a case where that could have been appropriate, which could have reduced pressure on the rehab end to figure out when it's appropriate to remove the NG, when it's appropriate to transition him to a PEG, and he did actually eventually end up with a PEG too. All right, so, all right, on this slide you're gonna see those two patient cases that support the need for better awareness of the prognostic indicators for dysphagia recovery after a stroke, use of evidence-based approaches for diagnosis, and the need for patients and caregivers to receive the appropriate education for decision making. Both of these patients were diagnosed with dysphagia based on a clinical swallow eval, which, as a reminder, has pretty poor reliability and is a screening tool. One was given a PEG, the other an NG tube, but both cases would have benefited from a better understanding of the prognostic indicators and risks. So and to wrap it up, I hope the takeaway for therapists and medical professionals is that diagnosis of dysphagia alone is meaningless without therapists conducting the appropriate assessments, accurately interpreting those assessments, and considering the relevant prognostic indicators for their patient's recovery. Standardization of instrumental assessment procedures, better education in the interpretation of instrumental assessments, and adequate time for those endeavors is paramount. And further research is gonna continue to be handicapped by poor diagnostic methods. For patients and caregivers, education on appropriate diagnostic methods, recovery prognosis, and a actual true discussion of the options for patients with dysphagia, including but not limited to aspiration pneumonia risks, risks and benefits of PO versus NPO, and determining NG versus PEG placement not only needs to be undertaken, but it needs to be undertaken with that full respect to patient and caregiver's rights to make their own choices and to not just be told what to do. And allowing NG tubes in acute rehab has provided more room for recovery and lessened the pressure to PEG early on. And it's a first step in incorporating dysphagia recovery prognostic indicators after stroke, PEG placement guidelines into actual clinical practice. All right, and with that, I'm gonna pass it on to Dr. Gonzalez-Fernandez. That is me. Well, thank you all. We've seen great information in this session, and we wanna open it to you guys to see what information you might need, what questions you might have, and to be able to understand this problem better. Any questions? Yep, I see someone. Yes, go ahead. I think that was an excellent presentation. Many of us have always felt that we tended to over-treat dysphagia, and we may be fussed One of my concerns is that there seems to be this assumption that NG tube's good, PEG tube's bad. I'm old enough to have treated stroke patients before we had PEG tubes, and NG tubes were really pain. They were uncomfortable. The patients always pulled them out. If you dislodge it partially, you can pump 2P directly to the lungs. I've seen that a couple times. Whereas PEG tubes, if you have a good surgeon, you've got very low complications. They're very easy to protect with a binder. There seems to be an assumption here that an NG tube is a good thing and a PEG tube is a bad thing. I would wonder about that. I would urge you to do a randomized study of PEG versus NG tubes and look at the complications of each. I think that would be very useful. Point well taken. That was part of presenting two cases that obviously one kept the NG tube when it was certainly not the right thing to do, while at the same time you had a patient who had all the indicators that they would recover early, but in fact still received a PEG. So it's trying to find that sweet spot that's important, and I totally agree a randomized control trial is needed. Any other comments from the team? Robin, do you have some of that data about complications? Yeah, we actually do have some analytics that we did on rates of complications, and we're working on the manuscript for this currently. But yeah, we did look at rates of NG tubes getting pulled, complications along those lines. So look for data from that forthcoming from us because we certainly are aware that it's not a panacea for all things. Great presentation, a lot of good information. As someone who does video studies for my stroke patients, I think it's great that you guys are considering it. It's interesting because our facility is working with the acute as well because I think a lot of this somewhat is financially driven as well because of length of stays. I'm not sure how long your stroke patients stay at your facility, but one of the big issues that we've come across is that they want to have as many stays as possible. And so in the NG tube to convert to a PEG tube, the time frame and actually consideration of that also plays a role in terms of insurance companies not paying us as long as we would like in acute rehab. So to try and schedule a PEG tube is also somewhat of a challenge too. That being said, I think it's great that you guys are doing that. I'm curious, you mentioned the standardization of the swallowing and now I know the speech therapies are all going towards the easy diets and stuff like that. Now we're starting to use a new standardized protocol where we're using thin liquid and moderate, moderately thick versus moderately thick and all those kind of things and going to a weight-intensity diet and going through that standardization. But as we know, not every patient really can follow that as well. And you kind of commented on your second case where you have a patient who's not cognitively really aware, very sedated. So the argument, like you mentioned, maybe it's better to put a PEG in before they get to acute rehab because then there's less that we have to worry about. And then you brought up a very good point that I have patients that complain about the NG tube all the time. And even with the bridal in, I've had NG tubes come out and we have some conceded patients or they get it overjoyed because someone who's sun-downed something can't come over and provide that. So I don't know if NG tube is necessary. I think we have to figure out what's going to be the best practice and what's going to be really convenient for when and I don't think it works in every facility. And I don't know how many rehabs actually have access to a DFSS in-house versus having to send them out because I know for me, we have to always worry about how many hours of therapy, right? Because it's standardized to three hours of therapy every single day. But if you send someone out for a study, then there's an hour or so of transport. We've been running into issues where our ambulances are hours delayed. So I think that's pervasive. And ever since the pandemic, I think there's been shortages. I don't know how you guys are handling some of those issues. Yeah, just to speak to some of the things you just mentioned. So we're very lucky because it is in-house for us. Our MBS suite is there. It's our session for the day. Speech takes them and does their MBS. So it's just right there for us. And in cases where you're talking about waiting for getting an ambulance to go out to do the MBS, that's where something like a mobile fees truck would come in handy. Having somebody who comes to you so you're not taking huge chunks of time out of the day to transport them. But I definitely understand what you're saying. And we do have kind of a privileged position, given that we have access in-house and that we are easily able to send people from our rehab facility to our medical center for PEG placement if needed. So it's a little bit of a different... Do you argue that it's better to have a BFSS on all patients before they can get to their acute rehab bed? Actually, to speak to what you said about the confused patient that I called Jeff, he did do bedside trials. So that's, to me, if he can sit there with you at the bedside and you can give him things to eat and drink and use a really low reliability clinical swallowy valve to diagnose him, why couldn't you take him to the fluoro suite and do that there? Or take the fees to him? Because we do have both. In my personal opinion, that's the biggest challenge we have. Like, we are not using screening tests appropriately. We're using it for diagnostic purposes and you really don't know what's going on unless you do an MBS or fees. And that should be done before you make the decision of whether the patient needs a PEG or not. Go ahead. Just one question. What was the drive of the decision protocol for the acute care? Yeah, those decisions are being made by multiple different neurology teams and I don't think that they actually have a standardized decision tree across teams. But you're absolutely right. That is something that we should evaluate with our providers on the acute care side. Some of the decisions are made by the general neurology teams or made by the neurocritical care teams. So I think there's practice differences and some of them are driven by GI. But you're absolutely right. I think we should look into that in some more detail and see if we can get some consensus about that practice. But it's an old problem, I agree with that. It did show that there was an increased mortality in the state of the UK, but I think there is an absolute resistance for the evaluation of that now to the federal. 2005, yeah, absolutely. And the third thing is... For the nurses that are not actually trained to deal with this area, they might look... in all rehab centers to reassess whether the person requires a peg or two for another test? I just wanna acknowledge that that's a pretty excellent point, I have worked also in skilled nursing facilities for rehab and seen many patients who have just been kind of stuck on a peg and they're like, that's just how they are for the rest of their life and have sent those people out for instrumentals and come back on a diet after years, so it's a good point. Thanks for this talk, it was very good, especially the prognostic factors and like those. Do you have any considerations for, particularly, I guess, standalone rehab hospitals and the decision to peg a patient or not before they go there based on the insurance and whether or not they need to or more so, I guess, the cost of sending the patient back from the rehab facility to get a peg placed and what's the, do you have that capability in house? I can try to answer that, so I will try to put on my administrator hat to answer this. We have to realize that insurance should not be the driving force, sometimes it is practical, that is the practical reality, but it should not be the driving force, so how we try to manage expectations is that in some patients, we will lose money, it will cost the hospital money, other patients, it will not cost the hospital money, but our driving force is that what should be best for the patient care and that's one step, so we do not take that into consideration, how much would it cost us to send the patient back to the acute care hospital to get the peg tube placed. And most of the time, we don't need to. One more, and yes, 86% of our patients recover, that was the insight we gained from this. I'm also excited about the second part and that little bit about the pros and cons of peg versus NG tube. When our clinicians, as they're progressing, we are thinking that we would get to a state where in the acute care hospital, we will have prognostic indicators, where we are confident that based on these, this patient will likely need a peg, so even if a peg is put in, it was probably the correct thing to do, or if this patient will not need a peg, and so NG tube is absolutely fine. And finally, and I fight this battle every day, and as a physiatrist, we should do it, is that we have to take the conversation to the insurance saying that this is not the right thing to do. And we, there's a lot of resistance to it, but we have to be at the side of the, at the side of the patient fighting with the insurance. If they are making life difficult for us, we have to make life difficult for them. That's how it works on a daily basis. Thank you. Last two questions. So I'm wondering what advice or data you can share for modifying our prognosis for hemorrhagic versus ischemic stroke? Because that seems like maybe a death that happened in our work, you guys can add to that. Yeah, thank you, Jen. So this study, actually we did have both hemorrhagic and ischemic stroke. I have not gone back and tried to do the sub-analysis on that yet, and we might not be adequately powered to do it, but we are continuing to collect data on this because absolutely, the trajectory, I think, could be quite different as for many of the domains of deficit between hemorrhagic and ischemic stroke. The timelines for resolution and likelihood of resolution differ between the populations, so that's an excellent point. I do think that we should try and maybe do that sub-analysis, see if we have adequate power, and then pick up some more data for that. Yeah, thanks. Last but not least. Specifically, the second case of Jeff, you mentioned that he eventually got a peg. Do you know how long after a stroke he got a peg, and did it affect his prognosis? So I really wish I had that data to give you. I really wish I did. It was probably, I wanna say it was about four weeks. He ended up being with us for a very long time and kind of moving around to different units. So I unfortunately do not have the answer. But it didn't affect his, I mean, they got it. They got a timely appointment for him. He got the tube and was discharged to a subacute. When you are doing your modified suburbation, you have NGs on, do you have to take the NGs out? Sometimes, it depends. We do it on a case-by-case basis, and sometimes if we go in and, for example, a couple months ago I had a patient whose NG was all twisted up, and so we obviously, it was getting in the way of everything, so we did have it removed and then replaced. So case-by-case. Yeah, one point that I wouldn't wanna get missed in the midst of the whole presentation is how important it was the point Jodi was trying to make about the standardization of the MBS or the video swallow study. You know, there are tools available that make the studies consistently so you can compare between studies, and you can do studies that are more meaningful because you're comparing apples to apples. So we're hoping that that keeps progressing and that we get better at standardization so we can bring better studies to understand what's the, ideally, we'll have all the patients that keep NG tubes not need them eventually and not need pegs, and ideally, all the patients that need long-term pegs would get them. So the closer we get to that, the better we will be. So thank you for your attention. Appreciate it. Thank you.

dysphagia

discharge delays

stroke patients

evaluation

PEG tube placements

NG tubes

physiatrists

dysphagia recovery

standardized diagnostic methods

education

multidisciplinary approach