Title: Speech-Language Pathology Management for Adults With COVID-19 in the Acute Hospital Setting: Initial Recommendations to Guide Clinical Practice
Authors: Namasivayam-MacDonald, A. & Riquelme, L.
Journal: American Journal of Speech-Language Pathology
Year of Publication: June 30, 2020
Design Type: Clinical Focus article
Purpose: “As such, the following preliminary document is intended to guide speech-language pathology practice when working in acute health care settings with patients with COVID-19.”
Do you remember in school (high school, undergrad, grad school, anywhere), where you were studying for an exam, going over all your notes and materials, feeling in utter despair and desparation because “How in the heck are you supposed to know all of the information?!?”
Then, a miracle happened and the teacher sent out a guide or study sheet to help you focus on what specifically you should be worrying about, thus removing the huge weights off your shoulders (and maybe ending the incessant and stress-induced snacking).
Okay, I obviously can’t equate the recent article to a miracle, but, I think we can all agree it’s helpful (sometimes anything is helpful in these times!).
It’s a quick read, and honestly just a summary for CLINICIANS, the frontline workers trying to do their best, where they are, with what they’ve got, to whomever they are able to help.
Instead of an in-depth review, I just wanted to share the quick points for others, and hopefully there’s a later time to read and decide if it’s something investing more collaboration and discussion around for your situation.
An quick obvious reminder, which I’ll likely repeat again is:
“This pre-liminary document is not intended to replace recommendations or mandates from other practice authorities, such as licensing boards, national associations, departments/ministries of health, or accrediting bodies.” p.1
So what went on behind the scenes to come up with this information?
The 2 authors (who, by the way, have many Google-able articles and credentials to back up why they were heading this research 😉 ), used professionally established relationships and contacts to collaborate with “Ten SLPs representing five countries (Brazil, Canada, Ireland, New Zealand, and the United States), the physiotherapist (representing Canada), and the physicians (representing Japan and Belgium) returned comments to the lead author.”
“This was done to develop consensus and help ensure that the recommendations would be applicable to a wide range of clinicians in acute care settings across the globe.” p.2
I won’t bore you with the specific criteria, guidelines, and protocols they used and referenced when coming up with recommendations, but let’s just say they did all that and the terms “AGREE II framework” and “physiotherapy guidelines for COVID-19” could easily be Googled (also just checkout their Appendix😉).
Here are their ‘main messages’ (these are literally the bullet points they give you in the article right away, I’m just copying them here for you all😉):
- Contact and droplet precautions “should be implemented consistently” when entering the room of a patient with COVID-19, and aerosol-generating procedures (AGPs) will not be performed (Canada, 2020). This means proper donning of gloves, a long- sleeved gown, a surgical mask, and a face shield.
- In the rare circumstance that SLPs do not have access to adequate PPE after conducting a point-of-care risk assessment, they should advocate for appropriate PPE in order to carry out their jobs in a comprehensive manner given their important role on the multidisciplinary team. During these exceptional circumstances, SLPs should also have the option of providing indirect methods of assessment through discussion with the medical team and/or using telepractice to assess, manage, and/or treat the patient to avoid direct patient contact that would result in unsafe exposure for both the patient and clinician.
- SLPs and speech-language pathology assistants need to perform a point-of-care risk assessment to determine the required PPE for each activity they will be engaging in, thoroughly review their individual facility’s policies and procedures, and advocate for appropriate PPE when necessary.
- Airborne precautions should be implemented when performing AGPs (Centers for Disease Control and Prevention, 2020). A respirator (N95 or FFP3 mask or powered air-purifying respirator) and face/eye protection should be used by all health care professionals present in a room where an AGP is being performed on a patient under investigation or confirmed to have COVID-19 infection. Whenever possible, AGPs should be performed in an airborne infection isolation room. In cases where an airborne infection isolation room is unavailable, consider performing AGPs in another isolated room.
- AGPs that SLPs may be involved in include (but are not limited to; Centers for Disease Control and Prevention, 2020)
- management of patients with laryngectomies,
- management of patients with tracheostomies,
- management of patients using noninvasive (e.g., BiPaP and CPaP) and positive pressure ventilation
- management of patients using high-flow oxygen (e.g., high-flow nasal oxygen delivery including single and double O2 setups),
- management of patients with nasogastric tubes, and
- endoscopic evaluations of voice and swallowing (e.g., fiberoptic endoscopic evaluations of swallowing, videostroboscopy, manometry; Royal College of Speech and Language Therapists, 2020)
- AGPs that SLPs should be aware of in order to ensure use of proper PPE include (but are not limited to)
- airway suctioning, other than inline suctioning;
- breaking closed mechanical ventilation system, intentionally (e.g., open suctioning) or unintentionally (e.g., patient movement resulting in disconnection from mechanical ventilation);
- nebulizer/airway treatments;
- active cycle of breathing techniques; and
- cardiopulmonary resuscitation
- SLPs’ activities that have the potential to be AGPs through triggering of a sputum-inducing cough reflex include (but are not limited to)
- oral care,
- oral mechanism exams,
- gag reflex testing,
- cough reflex testing,
- bolus trials,
- videofluoroscopy swallowing studies, and
- upper esophageal sphincter dilation with a balloon catheter.
- SLPs should triage, prioritize, and/or modify their services as is necessary and follow hospital guidelines for AGPs
- Where possible, gather collateral information, use telephone or virtual care (telepractice) to gather history, and observe status if safe to do so
- Prior to engaging directly with the patient, SLPs should ensure they determine the appropriateness of the referral and plan how they will minimize patient contact
- Try to maintain physical distancing and work with the most easily cleaned and appropriate equipment or aids to ensure patient safety
- Collaborate and coordinate with interprofessional partners. Consider bundling and coordinating procedures requiring two or more people to preserve PPE (e.g., if the nurse will be needed to help position the patient for your evaluation, complete your evaluation while the nurse is already in the patient’s room for another reason)
- If any clinical procedures are modified as part of a risk management approach to the COVID-19 pandemic, document this clearly in the health record
Now let’s move on to the ‘how’ regarding some of those recommendations above.
“The following tables present recommendations on how to prepare and manage the care of patients with COVID-19 in acute care settings.” p.9
If that seems too vague, they provide you with EASY TO READ & INTERPRET TABLES across multiple areas:
“outlines recommendations to assist the speech-language pathology workforce to plan and respond to the demand of caring for patients with COVID-19.”
“provides recommendations on prioritizing the speech-language pathology caseload and best practices for screening and assessment of patients with COVID-19 in the spirit of minimizing use of PPE and reducing risk of transmission.”
“provides recommendations for determining whom SLPs should treat when patients have confirmed or suspected COVID-19 based on available resources.”
Let’s talk about the “P” word: PPE.
I, nor the authors are here to tell anyone what to do (see opening statement above), we’re merely here to share the various and multitude of evidence suggests (or in my case, sharing what others have shared). We want to be safe as SLPs, we want our patients to be safe, we want our families/friends to be safe. So here’s some info and recommendations to consider in order to help that happen:
“The use of face shields can substantially reduce the short-term exposure of health care workers to larger infectious aerosol particles and can reduce contamination of their respirators.”
“However, face shields cannot be used as a substitute for respiratory protection when it is needed (Lindsley et al., 2014). Therefore, in the presence of a potentially cough-generating procedure, such as a clinical swallow evaluation, filtering face pieces (e.g., N95 masks) combined with face shields or powered air-purifying respirators will provide clinicians with the best-known protection from cough aerosols.” p.10
“They concluded that “the weight of combined evidence supports air-borne precautions for the occupational health and safety of health workers treating patients with COVID-19. Therefore, it is critical that SLPs recognize that many of their duties involve AGPs and will require adequate PPE.” p.10
Again, YOU do what YOU can and need to do, for YOU and YOUR situation. There’s more information and evidence in the article that speaks about particle sizes, weight, and transmission as well if you so choose to explore further.
I know you were thinking about it in the back of your mind too, “What about AAC for ICU and on the floors??”
“The following three tables outline AAC solutions and associated training for health care practitioners according to patient needs for patients with or suspected to have COVID-19.”
“Table 6 provides solutions for these patients who are in isolation but do not require mechanical ventilation and do not have any physical and/or language difficulties.” p.12
“Table 7 outlines AAC solutions when these patients are in isolation and re-quire mechanical ventilation but do not have any physical or language difficulties.” p.12
“Table 8 provides AAC recommendations for patients with or suspected to have COVID-19 who also have physical limitations and/or a language impairment.”
“Given that the majority of these patients remain in isolation while in acute care, without easy or regular access to loved ones or hospital staff, it is imperative that they are provided a means of communication.”
“However, the solutions presented should serve as important reminders during the pandemic to minimize direct contact with the patient when possible, implement single-patient solutions where possible, use the patient’s own devices if available, and provide appropriate training to all members of the medical team.” p.12
Just a quick note, because even though I’m not totally reviewing this article, it’s still always important to weigh the prons and cons to everything (like when I tried to cut my own bangs: Pros- I got to buy a lot of new headbands and learned that I am not a hairstylist, Cons- I had to look like an idiot for a month🤦♀️🤦♀️).
Luckily, the authors also laid this out plain and clear in regards to their article as a whole [paraphrased by me]:
- clarifies urgent need for acute care SLPs
- based on most recent/relevant COVID-19 clinical practice guidelines/recommendations from ‘top-notch organizations, associations, and peer-reviewed studies’
- representative of international group of SLPs with sufficient clinical experience, academia, and leadership
- ever-changing clinical guidance given the nature of constantly newly learned information, evidence, etc. (obviously..)
- No patient was included in the author/reviewer group
- Due to the urgency of the issues, balancing a more rigorous process is difficult, so less consensus was achieved compared to other similar articles
Also! The authors already planned future updates including more formal explorations to produce additional reviews regarding COVID-19 and the relationships with speech-language pathology in about 6 months (November 2020), returning again after an additional 6 months after that (May 2021). So, sometime to look forward to, right?
Told’ya, short and sweet today. As with all the article reviews, these are quotes and info from my own notes that I’ve interpreted to be important and helpful to me as a clinician, so I really do recommend going straight to the reference to read in its entirety (it’s not long, but maybe not after a super long day😊) in order to see if there’s more that you can takeaway. ❤️
How can you use this article?!?
Honestly, that’s up to you! We’re all in different circumstances, different settings, different expectations, different demands, the list could go on and on.
Maybe you’ve been trying to advocate using AAC more?
Maybe you’re department has had pushback for deciphering PPE?
Maybe this was a relief knowing you’ve been able to implement some of these already?
Whatever your situation, I hope the the information finds you and is able to help in some way. ❤️
And ignoring the fear of sounding too repetitive:
“This is a preliminary document, intended to summarize suggestions for speech-language pathology practice in the face of the COVID-19 pandemic. Given the evolving health care crisis and the constant emergence of new information, the potential for omission of information is possible. As such, this document should not be viewed as the end-all document on this topic” p.3
Article Referenced: [FREE ACCESS]
Namasivayam-MacDonald, A., & Riquelme, L. (2020). Speech-Language Pathology Management for Adults With COVID-19 in the Acute Hospital Setting: Initial Recommendations to Guide Clinical Practice. American Journal Of Speech-Language Pathology, 1-16. doi: 10.1044/2020_ajslp-20-00096
Additional related information, evidence, and articles that have been published:
COVID-19 Information and Resources: Risk Management of AGPs for Dysphagia Care [Updated May 6, 2020]
Dysphagia Care Across the Continuum: A Multidisciplinary Dysphagia Research Society Taskforce Report of Service-Delivery During the COVID-19 Global Pandemic
Using Masks for In-Person Service Delivery During COVID-19: What to Consider
(Many others to be honest!!)