1. Speech & Language Therapy in Critical Care
Gemma Jones
Specialist SLT Critical Care

2. 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)

3. 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.

4. 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

5. Role of SLT on ITU Optimising secretion load
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

6. Role of SLT in tracheostomy weaning
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

7. 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.

8. 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)
Anedotaly I feel this is much higher than figures reported and is often under reported due to all the other ‘life threatening’ concerns during ITU stay. Figure does go much higher on reported from outpatients reflecting on ITU stay

9. 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).

10. Challenges in Critical Care
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

11. The ITU Experience

12. 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
Firstly thinking about the patients at LTHT.
My vision is for SLT to provide a high quality service in critical care. We will aim to achieve a service for critical care service that is equitable with other patient groups in the hospital. Speech and Language therapy will be an integrated member of the MDT, attending all meetings and ward rounds. We will contribute to the provision of organised and early assessment and rehabilitation in order to improve physical recovery, minimise any psychological problems and maximise quality of life. Our service will be reactive, aiming to respond to new referrals within 1 working day and provide FEES assessment as required. It will also be proactive, seeking new referrals at ward rounds and MDT meetings. SLT contribution to patient management in critical care will help to reduce the length of stay both in critical care and overall length of stay 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)

13. Improving safety: Patient engagement:
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
We will aim to provide safe care for our patients by providing specialist assessment for patients post-extubation and tracheostomy and ventilator dependent patients. This will help to reduce the frequency of aspiration pneumonia and mortality rates. Appropriately identifying and managing dysphagia will enable the reduction of re-admission to both critical care and hospital.
? references
1 NICE Guideline: Rehabilitation after Critical Illness (2009)
2 RCSLT Position Paper SLT in Adult Critical Care (2014)

14. Clinical outcomes: Education:
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
We will ensure that we are achieving excellent clinical outcomes by maintaining accurate statistics of SLT input and regularly auditing intervention outcomes. This will enable ongoing review and improvement of the SLT service.
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)

15. 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
It will be vital to develop relationships in critical care so that SLT is an established member of the MDT in order to contribute to decision-making with regard to pathways and policies, such as tracheostomy management and oral care.
I would be keen to try to collaborate with Maggie-Lee Huckabee and conduct a research project introducing a CRT protocol for all post-extubated neuro patients in ITU. It is essential that there is strict data collection for the benefits of SLT input in critical care e.g. decreasing time to decannulation, reducing LOS, improved quality of life in order to prove our worth and so further develop services. Furthermore, SLT will contribute to the wider critical care MDT audit and research as well as national audit in order to support service development decisions and benchmark against other services.
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)

16. Challenges New role No functioning MDT Tricky characters
Barriers to change
Time
Sole SLT
Geography

17. Success

18. 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

19. 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

20. Questions?

21. 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.

22. References
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)
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.