By: Pam Ragland, MS, CCC-SLP, Business Management Committee Member 

Since the onset of the global pandemic of the coronavirus disease 2019 (COVID-19), the media has made us aware of many issues and changes in hospital settings. Patient treatment in the home setting also has been affected. Speech-language pathologists (SLPs) who are providing home health treatment are being asked to provide care for medically complex patients more frequently. 

Before the pandemic, patients with respiratory failure who required a tracheostomy with ventilator support progressed through acute to sub-acute settings including hospitals, acute rehabilitation centers, long-term care with rehabilitation, and finally outpatient or home health services. Due to the recent limited capacity at hospitals and rehabilitation centers, not all patients have been able to progress through multiple levels of care at various facilities. The outcome has resulted in more patients with respiratory deficits and severe dysphagia being sent home to their families, who then are faced with managing numerous and compounding medical issues. 

Healthcare staff have been overworked in hospital and rehabilitation facilities throughout the pandemic, and home health staff also have been overextended by taking on larger and more complex caseloads. Not all treating home health therapists are prepared for nor experienced in evaluating and treating this level of medical complexity. The American Speech-Language-Hearing Association (ASHA) states that the SLP “shall engage in only those aspects…that are within the scope of their professional practice and competence.” The SLP should ensure his or her skills and knowledge meet the criteria for treating the needs of the patient and look for opportunities to advance knowledge and skills. Home health is a unique therapeutic environment in that healthcare workers are typically visiting the patient’s home one discipline at a time. Unlike other settings, there are not multidisciplinary staff down the hall when assistance or consultation is needed regarding issues such as respiratory status changes, help with a transfer for feeding, or questions about ordering equipment. Therefore, the SLP must reach out and connect with additional sources and networks to provide the care needed for the more medically complex patient in the home setting. 

Know Which Questions To Ask
Optimal treatment involves learning from patients as well as their families. The SLP should initially assess the patient’s communication and swallowing function and evaluate the patient’s and caregiver’s understanding of safe care routines. Making an effort to spend an equal amount of time talking as well as listening to the patient and caregiver develops rapport and allows for the opportunity to express empathy and support. Encouraging open communication may help to obtain more complete information, enhance accurate assessment of needs, and facilitate appropriate training and discussions. In turn, a partnership can be developed that allows room for explanations, cultural respect, and trust. 

Know Your Resources
Other disciplines, especially nursing, are important partners to ensure timely and appropriate referrals are made. Nurses typically are visiting more frequently than SLPs and are more likely to see subtle changes in functioning immediately. The SLP can provide nursing staff with simple dysphagia screening tools to help them make timely and appropriate referrals when swallowing status changes. The Swallowing Algorithm Post Extubation (SAPE) is one example of a screening tool that has been developed specifically for patients who have experience prolonged intubation. Many healthcare workers can utilize this tool easily since some of the information is based simply on medical records as well as observation of the patient. ASHA has outlined some central items that should be considered when selecting a dysphagia screening test including a review of the history of dysphagia, a medical diagnosis that affects swallowing, overt signs of aspiration, complaints of swallowing difficulties, and a pass or fail recommendation. Making screening tools available can make early assessment more complete and easier for other disciplines. 

For the SLP working with patients who have a tracheostomy, a respiratory therapist is another key resource. SLPs and respiratory therapists can both benefit from sharing knowledge of overlapping areas of respiration and swallow function. Respiratory strength training and breathing-swallowing coordination exercises can be initiated through consultation and collaboration with respiratory therapy. Additional areas of shared decision-making could include determining when and how long a patient can be off ventilation, monitoring suctioning needs of the patient, and determining if a patient is a candidate for a one-way speaking valve. 

One-way speaking valves redirect air flow through the vocal folds, mouth, and nose, enabling voice and improved communication, and have been shown to improve protection of the airway from aspiration of excessive secretions and food or liquids when eating orally (Licktman et al. 1995, and Siebens et al. 1993). The use of a one-way speaking valve is initiated when a patient meets an assessment criteria specified by the valve manufacturer. Patients who have a tracheostomy tube with an inflated cuff must be able to tolerate deflation when a one-way speaking valve is attached. Together, respiratory therapists and SLPs help the patient transition from an inflated cuffed tracheal tube to gradually tolerating a deflated cuff or a cuffless tube. A one-way speaking valve is placed on the outside opening of the tracheostomy tube, which allows air to pass into the tracheostomy but not back out of it. When the patient breathes in, the valve opens. When breathing out, the valve closes, and air is directed around the deflated cuff or cuffless tube and exits through the upper airway. 

Suiter (2003) stated that scores on the penetration-aspiration scale for thin liquids improved when a patient was able to tolerate a deflated cuff with placement of a one-way speaking valve. Gross et al (2006) found evidence that greater lung volume is achieved with one-way speaking valves and increases subglottic air pressure during the swallow. The swallow function moves toward a normal pattern, which increases the potential for reducing aspiration risk. 

Training caregivers to use safe protocols is essential for use of one-way speaking valves. This can include providing suctioning of the tracheostomy tube as needed, possibly applying oxygen or humidity, educating when and how to deflate a cuff if present, and how to attach and detach the one-way speaking valve as well as care and cleaning of the valve. Patient and caregiver goals can be directed toward weaning a patient from a ventilator and trachea as well as developing safer protection of the airway for swallowing. 

Patients who are using a one-way speaking valve while on a ventilator require training to coordinate breathing and speaking. The design of the ventilator allows speech to occur during expiratory cycles. The normal rhythm of give-and-take conversation will be different and should be practiced in context of the patient’s familiar environment. There will be a long pause between speech efforts while the ventilator provides the inspiratory phase. The patient will need to learn to listen and wait for the expiratory phase to initiate speech. Caregivers and family also will need to learn to wait for the patient to speak as the expiratory phase of the ventilator occurs and avoid filling long silences so the patient does not lose his or her turn to speak. 

Know Your Referral Options
Families often find their heartfelt effort to care for their loved ones is more stressful and complicated than they anticipated. Training provided by the home health multidisciplinary team may be enough for some families and caregivers, but others may require additional resources. This can range from in-home caregivers, meal delivery sources, lists of phone contacts for questions regarding use of medical devices/equipment, and setting up training and schedules for new healthcare routines. Referring to social services or nursing to provide a list of liaisons that can assess the patient’s needs and connect families to outside services can help meet the additional needs of patients and caregivers. 

We Learn by Working Together
SLPs must follow the ethical guidelines for practicing with competency or refer to another SLP when it is outside his or her scope of expertise. The SLP can build on established areas of specialty through education and training. The pandemic has brought us into a new educational culture of endless access to many online courses and webinars that provide excellent learning opportunities. Manufacturers of ventilators, speaking valves, and suctioning devices are providing online training, many of which are free and readily accessible in addition to peer-reviewed articles and webinars.

Learning a new skill should never be completed in isolation. Cross-training with other healthcare workers can finetune newly learned skills. Scheduling overlapping sessions of treatment with respiratory therapy and nursing to develop understanding of equipment use is usually welcomed. Co-treatments with other disciplines allow opportunities to observe and perform new tasks while team members provide coaching. This can be an opportunity to communicate progress in overlapping areas of treatment. Those of us who entered the healthcare field have a heart to help others including our own healthcare team.

Home health SLPs who receive referrals that are medically complex should connect with all of those involved in the patient’s care. The medically complex patient has many overlapping needs, and interfacing with other disciplines can lessen the treatment burden and also provide a more complete treatment paradigm. We need other disciplines in the healthcare field as much as our patients need us. Connecting team members, including the family and patient, brings an enlarged view of the possibilities that treatment can provide for achieving optimal success in all therapies. 

References

American Speech-language Hearing Association. (2016) Code of Ethics [Ethics]. Available from www.asha.org/policy.

American Speech-Language-Hearing Association. (n.d.). Adult Dysphagia. (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Clinical-Topics/Adult-Dysphagia/.

Evans R, Catapano M, Brooks D, Goldstein R, and Avendano M. Family caregiver perspectives on caring for ventilator-assisted individuals at home. Canadian Respiratory Journal. 2012 19(6): 373-379.

Frajkova Z, Tedla M, Tedlova E, Suchankova M and Geneid A. Postintubation dysphagia during COVID-19 outbreak-contemporary review. Dysphagia. 2020 35:549-557.

Johnson KL, Speirs L, Mitchell A, Przybyl H, Anderson D, Manos B, et al. Validation of a postextubation dysphagia screening tool for patients after prolonged endotracheal intubation. American Journal of Critical Care. 2018 27:89-96.

Lichtman SW, Birnbaum IL, Sanfilippo MR, Pellicone JT, Damon WJ, and King ML. Effect of a tracheostomy speaking valve on secretions, arterial oxygenation, and olfaction: a quantitative evaluation. Journal of Speech and Hearing Research. 1995 38, 549-555.

Siebens AA, Tippett DC, Kirby N and French J. Dysphagia and expiratory air flow. Dysphagia. 1993 8:266-269.

Skoretz SA, Anger N, Wellman L, Takai O, and Empey A. A systematic review of tracheostomy modifications and swallowing in adults. Dysphagia. 2020 35:935-947.