Transcript Role of speech and language therapist in critical care

Speech & Language Therapy
in Critical Care
Gemma Jones
Specialist SLT Critical Care
National Context
• Intensive Care Society (2015) – Guideline for the
Provision of Intensive Care Services
• SHINE report (2014) - Improving Multi disciplinary
tracheostomy care
• NCEPOD (2014) – On the Right Trach?
• RCSLT (2014) Position Paper for Critical Care
• National Tracheostomy Patient Safety Project (2012)
• NICE (2009) – Rehabilitation after Critical Illness in
Adults
• Quality Critical Care (2005)
All of these documents emphasise the
important of truly multi- disciplinary care
to build suitable improvements in quality
of care provided for our vulnerable
patient cohort.
SLT in Wales
• All UHB provide a level of SLT to Critical Care patients
• Resourced within existing SLT establishment
recognising patient need
• One funded post solely for Critical Care – Cwm Taf
• Number of business cases submitted to extend SLT
services to Critical Care
• Impacts on service to patients, to MDT involvement
and development initiatives
Role of SLT on ITU
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Level of alertness/response to stimulation
Optimising secretion load
Prevention of hypersensitivity & atrophy
Cranial nerve function
Suitability for tracheostomy weaning
Trial of Passy Muir (PMV)/Speaking valve
Strategies for effective communication
Appropriacy for alternative communication (AAC) device
Swallow functioning
Language ability/function
MCA assessments with MDT
Early family support and family involvement
Role of SLT in tracheostomy weaning
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To assess suitability for and tolerance of cuff deflation in conjunction
with MDT.
To provide specialist advice of the management of oral hygiene and oral
secretions / saliva in patients who are dysphagic/at risk of dysphagia.
To carry out screening assessment of laryngeal pathology that may
require further clinical specialist investigations i.e. ENT
To assess voicing ability, using either leaked speech or a speaking valve
and to provide guidelines for the use of these.
To provide specialist advice and treatment to enhance voice quality, in
conjunction with ENT findings.
To provide specialist evaluation of swallow function - include
videofluoroscopy or Fibreoptic Evaluation of Swallowing (FEES) when
indicated
Feedback from patients
• “The worst … part of my stay in intensive care was having no ability to
communicate … and what did that mean? It meant no say in my care, no
choices, no questions, no ability to reach out and no ability to be
reached…” Patient after ITU stay.
• “It was such a huge step forward when he could start to eat again. It was
the first time he smiled since before his heart operation.” Wife of patient
• “That was the best hour of my whole time since being in hospital”
Patient, Cwm Taf UHB after using his voice for first time since his
tracheostomy with use of Speaking valve to speak to his wife on the
telephone on her birthday and SLT assessing his swallow.
Effects of impaired communication
• Prevalence of communication difficulties =16-24% (Thomas &
Rodriguez, 2011)
• Difficulties communicating are associated with:
- Increased anxiety and fear (Menzel 1998; Armando 2002)
- Depression, powerlessness, depersonalisation, sleep
disturbance and loss of decisional control (Happ 2001)
• Although this is a temporary situation and many patients make a
good recovery, the psychological effects can be long lasting.
(Russell, S. 1999, Hemsley et al, 2001)
• Unless quality of life issues are addressed, effective treatment by all
team members is compromised.” (Dikeman & Kazandjian 2003)
Barriers to communication in ITU
• Communication occurs most often in conjunction with
physical care – highly clinical
• 71% of interaction with a patient in ITU is < 1 minute.
• Undervaluing of communication can occur due to the level of
arousal / medications (Hemsley et al 2001).
• Mechanically ventilated people report high levels of
frustration when communicating their needs (Patak et al
2004).
Challenges in Critical Care
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Medical status/fluctuations
Medication and sedation
Ventilation – ETT, trache
Environment – noise,
workload
Cognition/delirium
Neuro impairment
Psychological issues
Pre morbid functioning
Motor involvement incl.
oedema/weakness
The ITU Experience
Aims of Critical Care SLT service
• Quality:
– Achieve equity of access to SLT services for people in
critical care 1,2
– SLT to be an integrated member of MDT in providing
organised and early rehabilitation in order to
maximise quality of life, improve physical recovery
and reduce psychological problems post-critical
illness 3,4,5
– Provide a proactive and responsive SLT service
– Reduce LOS in critical care and in hospital
1 RCSLT Position Paper SLT in Adult Critical Care (2014)
2 DOH: NHS Improvement Plan Putting People at the Heart of Public Services (2004)
3 NICE Guideline: Rehabilitation after Critical Illness (2009)
4 ICS: The role of healthcare professionals within critical care (2002)
5 NICE guideline: Major trauma service delivery (2016)
• Improving safety:
– Contributing to reduction of aspiration pneumonia
– Reduce recannulation rates within UHB
– Reduce hospital and critical care re-admission
rates
• Patient engagement:
– Ensure assessment and facilitation of
communication in order to enable patients to
have a voice and participate in decision-making
regarding their care1
– Facilitate Mental Capacity Assessment2
– Regular audit of patient satisfaction in order to
improve service
1 NICE Guideline: Rehabilitation after Critical Illness (2009)
2 RCSLT Position Paper SLT in Adult Critical Care (2014)
• Clinical outcomes:
– Maintaining accurate statistics of SLT input
– Regular audit of SLT and MDT intervention outcomes 1
• Education:
– SLT team
– MDT team:
• Role and value of SLT in critical care1
• Impact of intubation, tracheostomy, ventilation,
delirium/ITU psychosis, sedation, anti-psychotics, critical
care acquired weakness on swallowing and communication
• Dysphagia assessment and intervention
• Communication assessment and intervention e.g. AAC2
• Advice and input for complications e.g. hypersensitivity3
• Making referrals
1 Mestral et al. (2011). Impact of a specialized multidisciplinary tracheostomy team on tracheostomy care in critically ill patients.
Canadian Journal of Surgery, 54 (3)
2 ICS: Core Standards for Intensive Care Units (2013)
3 RCSLT Position Paper SLT in Adult Critical Care (2014)
• Research and Innovation:
– SLT to be a valued and established member of MDT in
critical care1 and contribute to decisions around
pathways and policies e.g. tracheostomy and oral care
– Project to introduce CRT for all post-extubated neuro
patients in ITU
– Collating evidence for benefits of SLT input in critical
care2
– Contributing to MDT audit and research on critical
care3
– Contributing to national audit e.g. Intensive Care
National Audit Research Centre (ICNARC)4
1 National Tracheostomy Safety Project (2010)
2 RCSLT Position Paper SLT in Adult Critical Care (2014)
3 Critical Care Stakeholder Forum: Quality Critical Care: Beyond ‘Comprehensive Critical Care’ (2005)
4 ICS: Core Standards for Intensive Care Units (2013)
Challenges
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New role
No functioning MDT
Tricky characters
Barriers to change
Time
Sole SLT
Geography
Success
Successes
• Introduction of Passy Muir valves in ventilator
dependent patients to allow early verbal
communication.
• Raising profile of SLT role & value within
critical care
• Good patient feedback
• Development of policies/procedures relating
to SLT for Critical Care
Future Developments
• Increased MDT working for patient with
tracheostomies
• Additional funding for staff
• Competencies programme for SLTs
• Train SLT colleagues to provide cover
• Succession planning
Questions?
References
• Allied Health Professionals (AHP) and Healthcare Scientists (HCS) Critical
Care Staffing Guidance: A Guideline for AHP and HCS Staffing Levels (2003)
National AHP and HCS Critical Care Advisory Group
• Critical Care Stakeholder Forum: Quality Critical Care. Beyond
“Comprehensive Critical Care” (2005). Department of Health (England)
• Department of Health: NHS Improvement Plan Putting People at the Heart
of Public Services (2004) Department of Health (England)
• Department of Health: Modernising AHP Careers: a competence-based
career framework (2008). Department of Health (England)
• Intensive Care Society (2013) Core Standards for Intensive Care Units. The
Faculty of Intensive Care Medicine/The Intensive Care Society
• Intensive Care Society (2002) The role of healthcare professionals within
critical care. The Faculty of Intensive Care Medicine/The Intensive Care
Society
• KSF: Critical Care Patient Group (2006) London: Royal College of Speech
and Language Therapists.
References
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Mestral, C., Iqbal, S., Fong, N., LeBlanc, J., Fata, P., Razek, T. & Khwaja, K. (2011).
Impact of a specialized multidisciplinary tracheostomy team on tracheostomy care
in critically ill patients. Canadian Journal of Surgery, 54 (3)
National Tracheostomy Safety Project (2013) www.tracheostomy.org.uk
NICE guideline: Acutely ill patients in hospital (2007) CG50. London: National
Institute for Health and Clinical Excellence
NICE guideline: Major trauma: service delivery (2016) CG40. London: National
Institute for Health and Clinical Excellence
NICE guideline: Rehabilitation after Critical Illness (2009) CG83. London: National
Institute for Health and Clinical Excellence
RCSLT Position Paper SLT in Adult Critical Care (2014) London: Royal College of
Speech and Language Therapists
RCSLT Tracheostomy Framework Competency (2014) London: Royal College of
Speech and Language Therapists
Skills for Health (2010) Critical for Care: A Vision for Post Graduate Critical Care
Education and Training in Cheshire and Mersey: Designed by Professionals for
Professionals.