FEES in the SNF setting


Having access to FEES in the SNF setting is important for patient quality of life, patient safety, reducing costs, and improving patient outcomes. This article will go through each of those points.  As an SLP, it’s important to understand these points in order to be able to advocate for your patients.  For administrators, understanding that a FEES assessment can provide all of these benefits can help to manage the patient’s needs the best way possible.

Flexible endoscopic evaluation of swallowing is when an endoscopist passes a small flexible endoscope through the lower part of the nostril and into the pharynx, where it rests behind the uvula and looks into the lower pharynx. The video and audio are viewed on a monitor and can be reviewed later.  The patient is fed real foods and liquids that have been colored green or blue to improve visibility without the pharynx. FEES is used to assess the swallowing safety for patients with suspected dysphagia. 

According to the American Speech and Hearing Association: “Verification of aspiration and thorough assessment of impairments in swallowing physiology or laryngeal/pharyngeal/upper esophageal anatomy REQUIRE instrumental assessment.” ASHA, 2021



FEES and Quality of Life

An instrumental swallowing assessment can determine why the patient is having difficulty swallowing. It can determine the safest food and liquids for the patient.  There are so many patients where a patient might be coughing on thin liquids and therefore placed on thickened liquids in an effort to prevent aspiration.  There are a few issues with this practice.  Patients may be aspirating both thin and thickened fluids.  However some patients have a cough response to the thin liquids and silently aspirate thickened fluids.  Learn more in FEES and patient safety.  

Patients on thickened liquids also often do not enjoy the taste/consistency.  This effects their quality of life.  They also might reduce intake of liquids and become dehydrated.  

Then there are patients who may be receiving alternative nutrition and hydration.  Patients who are NPO with a PEG can be provided with the opportunity to determine if they can eat safely by mouth.  We can view the pharynx/larynx to determine if food or liquid has passed into the airway. 

FEES and Patient Safety

Patient safety is obviously of upmost importance. FEES can determine if the patient is aspirating and why. Patients may be more likely to silently aspirate thick liquids than thin liquids (Miles et al., 2018) and aspiration of thick liquids can lead to pulmonary injury (Nativ-Zeltzer et al, 2018).  Therefore if the patient is coughing on thin liquids at bedside and not on thickened liquids, this does not mean that the patient is not aspirating the thicker liquids.  Blindly placing patient on thickened liquids can be detrimental to the patient. 

SLPs are also missing silent aspiration at the bedside 14% of the time (Leder, 2002). Aspiration pneumonia is the leading cause of death for SNFs, and residents that are diagnosed with aspiration pneumonia have a mortality rate three times higher than other residents (Oh et al, 2004)

FEES and Reducing Costs

Sometimes administration may only see the costs associated with performing a FEES at the nursing home.  However, FEES can SAVE money for facilities in a few different ways.  Aspiration pneumonia may be prevented.  Each pneumonia costs around $30,000.  Pneumonia is a leading cause of death and rehospitalization, particularly in a frail population.  Patients can be kept safely at the skilled nursing facility longer by preventing aspiration related pneumonia. 

CHF, respiratory infections, UTI, sepsis, and electrolyte imbalance account for 78% of all 30 SNF rehospitalizations and are potentially avoidable with careful monitoring of fluid and nutritional intake as well as appropriate positioning with swallowing disorders that can lead to pneumonia.

Furthermore, thickened liquids may be recommended at bedside when they are not required.  Thickened liquids cost $2,000-7000 per year and are often unnecessary (Richard, 2018). Patients tend to find thickened liquids less palatable, therefore drinking less which often leads to dehydration (Daniels and Huckabee, 2014).

FEES is also 1/4 of the price of sending the patient for a Modified Barium Swallow Study. 

FEES and Improving Patient Outcomes

FEES is not only performed to determine if a patient penetrated or aspirated.  It also can determine the “why.”  In understanding the physiology of the swallow, we can now rehabilitate the patient with an individualized treatment plan.  No more guessing which exercises to implement.  

NDoscopy Dysphagia Specialists provide objective information with data for tracking outcomes.  We can track certain characteristics of the swallow to compare to a previous exam to determine improvement. Our documentation can be used to provide objective information about the necessity of skilled dysphagia therapy.  

No Exclusive Contracts

Per CMS regulations, exclusive contracts are illegal for diagnostic purposes. We provide a pricing arrangement with the facility and it is a fee for service so there is nothing to lose. You can always go back to sending the patient to the hospital.


FEES is a safe, cost effective exam to provide evidence-based dysphagia management to patients in the skilled nursing environment. NDoscopy can come to your facility to provide a free inservice on the benefits of FEES and answer any questions.  Give us a call at 646-389-4316. We provide the service on average between 1-2 days of consult.  

Improving quality of life for patients with dysphagia one scope at a time.


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