Videofluoroscopic Swallowing Study (VFSS) Referral Form

Speech Pathology Department - Royal North Shore Hospital

Email: NSLHD-RNS-SpeechPathology@health.nsw.gov.au Phone: 9463 1622

What is a Videofluoroscopic Swallowing Study?

A VFSS (or modified barium swallow) is a dynamic videofluoroscopic assessment of a patient’s oropharyngeal swallowing function. It assesses function and supports in diagnostics of dysphagia to guide best management with objective information. This is in contrast to a barium swallow which assesses oesophageal function.

Why conduct a VFSS?

To define abnormalities in the oropharyngeal anatomy and/or physiology relating to symptoms of dysphagia;

To identify and evaluate treatment strategies, manoeuvres, and/or modification of food/fluids, that may immediately enable the patient to eat/drink safely and efficiently;

To evaluate the presence and reason for aspiration;

To gain further information to guide swallowing management, following a speech pathology clinical assessment.

What are the contraindications for VFSS?

Suspected oesophageal abnormalities without oropharyngeal difficulties;

Unable to maintain alertness for > 20 minutes;

Unable to maintain adequate head & postural control in a sitting position, or bed-bound;

Inability to cooperate with study (e.g. lacking insight, severe agitation, reduced level of alertness/drowsy or significant cognitive limitation);

No prior speech pathology assessment;

Clinical management is unlikely to change following the VFSS.

Referral Process

Referrals including completed paperwork should be forwarded to:

Speech Pathology Department, ASB Building, Ambulatory Care, Royal North Shore Hospital, Reserve Road, St Leonard’s NSW 2065	OR

NSLHD-RNS-SpeechPathology@health.nsw.gov.au

For clinical enquiries (including suitability of referral) please contact the Speech Pathology Department on 9463 1622.

Wheelchair Measurements

Any wheelchair that exceeds these measurements will not be suitable for the examination.

Videofluoroscopic Study of the Swallowing

Referrer Checklist

1. Contact managing medical officer and request referral for VFSS study.

2. Explain the procedure to the patient and obtain informed consent.

3. Complete and send this paperwork via mail, fax or e-mail. Once paperwork is received, the patient will be triaged and you will be contacted to book the patient into clinic.

4. Arrange for patient to be transported to Radiology Department, Royal North Shore Hospital on provided date.

Patient Name:	MRN:
Address:	DOB and age:
Allergies/infections e.g. MRSA etc
Inpatient or outpatient?
Referrer name:	Telephone number:
Email:	Facility:
Managing medical officer name and contact details:
Would you like copy of the images?	Yes/No
Reason for referral/swallowing concerns
Medical and Social History:
Premorbid function: Usual diet and fluids. Usual communication/ cognition function
Interpreter needed?	Y/N – language
Clinician/family member/carer to attend?	Y/N – contact details
Reason for VFSS: What question are we trying to answer that cannot be answered at bedside?
Current function: Swallowing/communication/ cognition Current feeding techniques/equipment
Cranial nerve assessment impairments
Speech pathology hypothesis of dysphagia breakdown:
Current mobility /transfers/ head control

Radiology Request Form

Location and Directions

Clinic Times:	Thursday mornings 9:00-11.00 (30 minute time slots)

Location:	Royal North Shore Hospital, Level 2 ASB Building, Medical Imaging Department, Reserve Road, St Leonard’s NSW 2065

Speech Pathology Tel:	9463 1625

Medical Imaging Tel:	9466 - 4400