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Narrative Review
A case study of the development of a videofluoroscopy service:
Integration and collaboration between the speech &language therapy
and radiographer teams
M. North
*
, S. Holmes
Oxford University Hospitals NHS Foundation Trust, Radiology Department, Headley Way, Oxford OX3 9DU, UK
article info
Article history:
Received 15 December 2022
Received in revised form
9 April 2023
Accepted 11 April 2023
Available online 26 April 2023
Keywords:
Videofluoroscopy
Modified barium swallow
Gastrointestinal radiographers
Speech and Language Therapists
abstract
Background: Videofluoroscopy (VFSS) is a dynamic fluoroscopic examination of swallowing function to
assess oropharyngeal dysphagia. In the United Kingdom (UK), this test is typically perform ed by a team of
Speech and Language Therapists (SLTs), radiologists and radiographers. While VFSS is undertaken across
the UK, recent literature reflects wide variation in the procedure itself.
Objectives: The role of the advanced practitioner gastrointestinal (GI) radiographer within a VFSS service
will be illustrated by the narrative description of a VFSS service in a large NHS teaching hospital in
England.
The paper compares the existing VFSS service against recent literature outlining national practice, with
particular focus upon the growing role of the advanced practitioner GI radiographer. Existing pressures
upon the National Health Service (NHS) are examined as contributing factors. Lastly, further plans to
improve the clinic are delineated.
Key findings: Recent literature shows a wide national variation in the running of VFSS services. Perti-
nently, the evidence suggests that radiologists are becoming progressively less involved in these clinics,
with a move towards more practitioner-led services.
The changes to the described VFSS service are in line with national trends, and the described clinic is an
effective example of a practitioner-led service which fully utilises the role of the advanced practitioner GI
radiographer.
Conclusion: This paper demonstrates that a practitioner-led service can benefit both patients and staff.
Further improvement work is ongoing, with a particular need to involve service users and collect more
meaningful outcome measures.
Implications for practice: The growing move towards practitioner-led clinics is likely to continue. How-
ever, the wide variation in practice nationally and lack of consistent, recognised training that meets the
needs of both SLT and radiographers, needs to be addressed.
©2023 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
Introduction
Videofluoroscopy (VFSS) is a dynamic and complex fluoroscopic
X-ray examination of oropharyngeal swallowing function, per-
formed by speech and language therapists (SLTs) working in
collaboration with imaging personnel including radiologists and
radiographers.
1
It was first developed by Dr. Jeri Logemann who
presented her work at the American Speech-Language-Hearing
Association (ASHA) convention in 1976. Initially referred to as the
Modified Barium Swallow Study (MBSS) or Cookie Swallow Test, it
was then introduced to the wider SLT profession by the 1980's.
2
It is
now known by multiple variations of MBSS and VFSS. In this paper
we have used the more contemporary term ‘videofluoroscopic
swallowing study’(VFSS).
The Royal College of Speech and Language Therapists published
UK guidance on VFSS in 2013 (RCSLT), however two national sur-
veys published within the last 24 months captured wide variation
across the United Kingdom in how VFSS is currently performed.
3,4
Benfield et al.
3
conducted a national survey of SLTs working in
VFSS across the UK, with the intention of building an
*Corresponding author.
E-mail addresses: michael.north@ouh.nhs.uk (M. North), Samantha.holmes@
ouh.nhs.uk (S. Holmes).
Contents lists available at ScienceDirect
Radiography
journal homepage: www.elsevier.com/locate/radi
https://doi.org/10.1016/j.radi.2023.04.007
1078-8174/©2023 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
Radiography 29 (2023) 635e639
understanding of how VFSS clinics are conducted and to establish
the extent to which guidelines and research have been embedded
into practice. The findings were compared with a similar survey-
based paper published 15 years prior by Power et al.,
5
which
showed wide variation in VFSS protocols and minimal intra- and
inter-disciplinary training and supervision.
Benfield et al.‘sfindings showed that, in comparison to the Po-
wer study 15 years prior, in most UK settings, VFSS clinics are now
predominantly practitioner-led, with radiographers involved in
95.5% of clinics and radiologists rarely present. However, fewer
than 50% of radiographers were reported to have received specialist
training in VFSS and just fewer than half of the radiographers were
involved in analysis and reporting of the studies. Just half of the
clinics were reported to be using a standard assessment or analysis
protocol. The paper's authors stated that criteria already identified
in research literature and VFSS guidelines had not yet been fully
implemented in VFSS clinics. They advised collaboration with
radiology, more detailed and up-to-date national guidelines, and
greater uptake of specialist training.
Boaden et al.
4
surveyed imaging personnel across the UK who
were actively involved in VFSS clinics. Their paper also reported
high variance in clinical practice across all stages of the VFSS
procedure, noting a lack of VFSS guidelines for imaging personnel
in the UK. The survey also indicated that a practitioner-led model
was reported as most common at 64%, with just over 9% of re-
spondents reporting radiologist-led clinics. Almost 15% of clinics
were reported as being run by rotational radiographers without a
specificfluoroscopy or gastrointestinal imaging expertise. Formal
or in-house training had not been undertaken by 25% of radiog-
raphers, and over 60% reported not having been formally assessed
in their competency to practice. While only 9.4% of respondents
rated themselves as very knowledgeable regarding VFSS,
53.7% rated themselves as very confident in undertaking the
procedure.
Boaden et al.
6
reported that almost 40% of the centres surveyed
continue to produce two separate reports eone produced by SLT,
the other by the radiology team, often stored on separate systems.
Over 56% of reports were described as written by the SLT alone, and
only 9.4% were a collaborative effort by the SLT and radiographer.
Almost 25% of radiographers/radiologists were said to contribute to
the report, but only if asked by the SLT, which was described as a
(missed) opportunity to draw on the unique skills of both
professions.
Boaden et al.
6
also reported that almost 40% of services did not
carry out imaging in the anterior-posterior position, and only
around 10% routinely imaged the oesophagus within the VFSS
procedure. One advantage of not imaging the oesophagus is a lower
radiation dose. Another strategy to reduce radiation is reducing the
pulse rate: the lower the pulse rate, the less radiation emitted. Pulse
is defined at the number of pulse rate, or bursts of radiation, per
second (pps). The most common rates used in VFSS are 30 or 15pps,
however, the higher the pulse rate, the better the quality of the
image.
7
Studies undertaken using less than 15pps were reported by
28% of services surveyed, and some services reported conducting
studies at as low as 2pps. Just over 11% reported carrying them out
at 30pps. However, almost 47% reported that they could not in-
crease their pulse rate due to unsuitable equipment, with machines
described as ‘ageing’and producing poor quality images.
Similarly, to Benfield et al.,
3
Boaden et al.
4
concluded that there
is great variation across all VFSS practice domains; a systematic
review undertaken by the authors identified deficiencies in global
clinical guidelines which generate localised variation in practice.
4
They stated that there needs to be standardised and accredited
VFSS education and further research into international, interpro-
fessional VFSS guidelines.
There are several contributing factors to the current state of
VFSS practice within the UK. One issue is the quality and quantity of
medical imaging devices available in the NHS. A report in by NHS 75
England
8
highlighted a continuing increase in the age of medical
imaging across the United Kingdom. Another report by Halliday
et al.
9
revealed that the NHS has fewer CT and MRI scanners per
capita than most of the members of the Organisation for Economic
Co-operation and Development (OECD). A further report by Pro-
fessor Richard's independent review, commissioned by NHS En-
gland, of diagnostic services for the NHS
10
recommended that there
should be a large expansion of imaging equipment to meet the
increasing demand and to match other developed countries.
A further contributory factor is the current vacancy rate of
consultant radiologists across the UK, reported to be at 433 in 2020,
equivalent to one-in-ten posts unfilled, according to the Royal
College of Radiologists workforce census report of 2020. This report
also highlighted the fact that two-thirds of those vacancies were
still unfilled after a year. In 2021, it was reported that the current
estimated shortage had increased to 1939 consultant radiologists,
equivalent to 33% of the workforce.
11e16
Royal College of Radiolo-
gists (RCR) President Dr Jeanette Dickson, wrote,
“We cannot deliver adequate services to our patients. Not only is
there a shortage of radiologists, but radiographers and nurses too.”
(13 pg7). Another independent review commissioned by NHS En-
gland added the Covid-19 pandemic has only increasedthe urgency
for investment in diagnostic services to tackle the cancer backlog.
12
The shortage of radiologists should be considered in the context
of the increasing role of radiographers in advanced practice. This is
supported by a growing body of evidence which demonstrates that
radiographers, acting within a defined scope of practice and with
support from radiologists, can provide a quality service and
reporting of a comparable standard to radiologists. This frees up
radiologists to undertake more complex cases and offers a financial
saving, particularly through a reduction in outsourcing. There is
therefore a need to increase the reporting capacity of radiographers
in all modalities, including gastrointestinal and fluoroscopic im-
aging. Where this has already been implemented, there is evidence
of a reduction in patient waiting times and re-attendance rates,
which has had a positive effect on patient care.
13,17e20
In this paper, we will narrate the development of a video-
fluoroscopy (VFSS) service in a large NHS hospital within the
context of pressures upon National Health Service (NHS) imaging
services and professionals, and the recent national practice survey
findings. The narrative will aim to outline the development of a
practitioner-led clinic; to illustrate the role an advanced practi-
tioner gastrointestinal (GI) radiographer can fulfil within a video-
fluoroscopy service; and to outline the lessons that have been
learned throughout the development of the clinic. Plans for
continued improvement of the clinic with increased involvement of
service users will be delineated, alongside the development of
meaningful and measurable outcomes.
A videofluoroscopy service case study
The case study is based in one of the largest NHS teaching Trusts
in England, made up of four main hospital sites and over 1000 acute
inpatient beds. At present, the VFSS service is only offered at the
one hospital site. The VFSS service has evolved significantly since its
inception, with a period of intense service improvement occurring
over the last five years to bring the clinic more into line with
profession-specific guidance
1
and the excellent model described by
Newman and Nightingale.
21
These changes were underpinned by
the motivation to run a ‘gold-standard’service and utilise the full
scope of practice for both SLT and radiographers in a truly inte-
grated and inter-disciplinary model.
M. North and S. Holmes Radiography 29 (2023) 635e639
636
In its first iteration, prior to 2009, the VFSS service was
radiologist-led and based at one of the smaller, specialist hospitals
within the Trust. The procedure was undertaken using a theatre
mobile C-arm fluoroscopy unit and was similar to a standard
barium swallow, performed via administration of water soluble or
barium contrast only. It did not involve consistency-driven bolus
trials or therapeutic intervention, and focussed primarily on cri-
copharyngeal function. There was no SLT presence, and referrals
into the clinic were primarily from Ear Nose &Throat services.
By early 2009, the SLT team had begun to establish a presence
in the clinic. That same year, following retirement of the desig-
nated radiologist, an advanced GI Radiographer took on the role
previously held by the radiologist in the clinic, alongside
continued SLT presence. The GI Radiographers within the Trust are
required to hold a Master's level qualification (post-graduate)
qualification in GI imaging, and work alongside medically trained
Radiologists. The role of the SLT within the clinic continued to
expand, however there was still comparatively little inter-
disciplinary working and reporting was done in isolation, with
two separate reports produced by the SLT and radiographer, stored
on separate systems.
In 2016, the VFSS clinic moved to the main hospital site, with
utilisation of a brand-new state of the art floor-mounted static
digital fluoroscopy machine. It was anticipated that this piece of
equipment would vastly improve the quality of the studies as well
as increasing the scope of the practitioners' practice. At this point,
the clinic was formalised into a practitioner-led service, with
funding granted for continued SLT presence in the clinic. This was
the beginning of more intensive service improvement work.
Analysis and reporting of anatomy and physiology of the swallow
became a joint undertaking by the SLT and GI radiographers
involved in the clinic, with verification of reports performed by
gastrointestinal radiologists not directly involved in the clinic. The
change to a practitioner-led clinic was supported by the literature
which shows practitioner-led clinics increase access to clinics
without compromising safety and reduce costs when compared to
radiologist-led clinics.
17
Furthermore, practitioner-led clinics are
currently the most typical service model across the UK.
3,11,21,22
It was agreed in 2019 that verification of reports by a radiologist
was no longer a requirement, but their support would remain
available on request. This change was supported by previous audits
of VFSS reports, which showed excellent levels of agreement with
radiology-led verification. Subsequently, it was permitted for re-
ports to be verified by the GI radiographers and SLTs involved in the
clinic. This change was also driven by the retirement of one of only
two radiologists involved with the VFSS clinic and was equally
intended to reduce the burden on the remaining radiologists within
the trust, within the context of the national shortage of radiologists.
Ongoing audit of the VFSS service at the end of 2019 showed a
persistently high rate of inappropriate referrals into the clinic,
hence further changes were implemented the following year in an
effort to increase appropriate use of the clinic. A clearer referral
pathway was implemented following consultation with stake-
holders and external bodies such as NHS England, who provided
clarification regarding the role of VFSS in diagnostic imaging
pathways such as the ‘two-week wait’cancer pathway.
23
Further-
more, a triaging measure was introduced whereby referring SLTs
were required to have discussed potential referrals with the lead
VFSS SLT prior to requesting a medical referral. Repeat audit
demonstrated the efficacy of these measures to reduce inappro-
priate referrals and increase capacity in the clinic. Positive feedback
was received from referring SLTs regarding the benefits of discus-
sing potential referrals with an SLT colleague, such as increased
understanding of the application of imaging-based swallowing
assessment.
In 2020, the Modified Barium Swallow Impairment Profile
(MBSImP) was formally incorporated into the VFSS clinic as stan-
dard practice, to be used by all members of the team. MBSImP is a
standardised protocol to interpret and communicate swallowing
impairments
24
and is used in 20.8% of clinics nationally.
3
MBSImP
certification has historically been the remit of qualified SLTs, with
fewer than 10 radiologists certified in its use internationally.
25
However, the GI radiographers were accepted onto the course
and became the first of their profession in the UK to attain certifi-
cation in MBSImP in 2021. This example of teamwork is supported
by Peladeau-Pigeon et al.
26
who reported the optimal video-
fluoroscopic examinations can only be successful when both SLT
and radiographers work together.
The radiographers’certification in MBSImP, alongside previous
attendance at external and post-graduate training courses in
dysphagia and VFSS, stands in contrast to the 25e47.3% of radiog-
raphers across the UK who were reported as not having received
any specialist training in VFSS.
3,4
VFSS training has been shown to
improve accuracy and reliability in both the novice and experi-
enced clinicians.
27e29
Having both SLTs and GI radiographers
certified in the use of MBSImP increased parity in the skill base and
training of both disciplines, whilst ensuring the use of consistent
terminology, standardisation of processes, and reliability in the
undertaking, analysis, and reporting of imaging, which is supported
by MartineHarris et al.
30
Further changes made to the clinic over the last five years in-
cludes the agreement to perform the lateral and liquid bolus of all
VFSS studies at 30pps, with solids and oesophageal sweep carried
out at 15pps to reduce radiation dose, in line with As Low As
Reasonably Practicable (ALARP) principles as per IRMER guide-
lines.
31
While the published evidence does not yet unequivocally
support one over the other, on the balance it was decided 30pps
was most appropriate due to the amount of detail lost at the lower
pps rates, and due to the research showing that key laryngeal
movements for airway closure may happen within 4 frames at a
pulse per second rate of 30pps, and a lesser rate may affect the
ability to make safe therapeutic recommendations.
32e34
Further-
more, the evidence shows using a protocol such as MBSImP can
lower the overall dose exposure during a study.
34
Routine performance of an oesophageal sweep, whereby the
radiographer chases the bolus through the oesophagus to the
stomach to screen for oesophageal abnormalities, has also become
standard practice in the clinic. This is supported by the evidence
base as allowing timely referral for further investigation and
avoiding incomplete management of patients with dysphagia, thus
leading to improved patient health outcomes.
35,36
While there are
limitations to the information that can be gained about the function
of the oesophagus in the erect position with a single bolus, the
routine inclusion of the sweep as part of our clinical protocol has
reduced the need to perform subsequent barium swallows to assess
for oesophageal dysphagia. Furthermore, the sweep is not per-
formed if the oesophagus has been imaged in the last six months
and there are no changes to reported symptoms, preventing un-
necessary radiation.
Following the radiographers’certification in MBSImP and the
agreement to perform VFSS at 30pps, the protocol for performing
barium swallows was also updated. Historically, barium swallows
were primarily focussed upon the oesophagus and the whole study
imaged at 7.5pps, with little if any comment on the pharyngeal
swallow. The GI radiographers updated their protocol to perform at
least one loop of the pharynx at 15pps, reporting pharyngeal pa-
rameters as per the MBSImP component framework. This change
was undertaken to make barium swallows more accurate in iden-
tifying oropharyngeal dysphagia and to facilitate onwards referral
to SLT services but has yet to be audited.
M. North and S. Holmes Radiography 29 (2023) 635e639
637
More recently, in response tothe need for a more robust service,
a supernumerary SLT has been included in the running of clinics as
part of the Trust's SLT-specific VFSS competency framework. Only
one SLT is funded as part of the Trust's VFSS clinic, as per 23.6% of
the respondents in Benfield's
3
survey, however it was agreed that
the routine presence of a second trainee SLT would contribute to
team building, consistency of practice and consolidation of skills.
The radiography team implemented a similar change, with a su-
pernumerary radiographer present in most clinics working through
the Trust's VFSS radiographer competency framework.
The numerous changes to the service were culminated into a
VFSS Standard Operating Procedure (SOP) (see Supplementary
Materials), finalised in 2021, alongside finalised Trust-specific
competency frameworks for SLTs and radiographers working
within VFSS. Following the production of the SOP, a survey of pa-
tient experience was undertaken as a starting point for further
development work, and the feedback received from patients was
100% positive.
Conclusion
As outlined, the Trust's VFSS service has evolved significantly
since its inception, and we continue to refine our practice, aiming
towards a ‘gold-standard’practitioner-led service that fully in-
tegrates the depth and breadth of skills from both SLT and radiog-
raphers. The practitioner-led service model has many benefits for
staff and patients and suits the evolving landscape of pressures
within the NHS on clinical and imaging services. We believe the
service model outlined in this paper, as an example of a
practitioner-led service, demonstrates integration of the comple-
mentary clinical skills of radiographers and SLTs within the context
of VFSS, and this could be a replicable model across other similar
services. We also believe that the model is in keeping with the
statement made by RCR and SCoR in their 2012 teamwork paper e
“reporting teams should be the result of careful and considered
service development”, and “a successful reporting team is a suc-
cessful multidisciplinary group working together”.
37
The next aim for the service looking forward is to develop
meaningful outcome measures that best demonstrate the benefits
of this particular service model, but also for these outcome mea-
sures to be patient-focussed and meaningful to service users.
Noting that there is little existing research into the service user's
experience of VFSS, we aim to implement further improvement
work, ideally through evidence-based co-design, with engagement
from service users to shape further service changes and establish
outcome measures that have significance for patients. Lastly, we
echo the statement by Boaden et al. &Boaden et al.
4,6
which calls
for standardised and accredited VFSS education and further
research into international, interprofessional VFSS guidelines.
Conflict of interest statement
None.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.radi.2023.04.007.
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