Practice management:

• ADULT ACUTE CARE:
• COVID-19

Q: What are some dysphagia related considerations I should be mindful of when evaluating/treating a patient with SARSCoV2 (COVID-19)?

A: In the acute setting, many patients have a prolonged hospital course that may include intubation and eventual tracheostomy dependency. Some patients are being “proned” while intubated and sedated. Proning means the patient is positioned on their stomach as this lung disease attacks the posterior lung, therefore proning helps offload pressure and can improve ventilator synchrony and patient oxygenation. Once patients are extubated or converted to tracheostomy status, their dysphagia severity will range from mild to severe (like most post extubation patients). Of note, the COVID population recovering from critical illness has difficulty maintaining stable oxygen saturation levels (above 90%) and experience poor endurance for a lengthy period. Throughout the day, the post extubated COVID patient may wear a variety of oxygen devices- nasal cannula, off/on high flow nasal cannula, off/on bipap or off/on non-rebreathers during their acute recovery. This fluctuation of oxygen needs, and awareness of poor endurance should be top considerations for PO intake (by mouth). Expect to make very specific recommendations related to timing of PO, positioning of the patient, pacing and signs indicating the RN/feeder should discontinue PO. Many patients will require supplemental nutrition during their acute phase of recovery (via nasogastric tubes or IV).

Protocols on how you will evaluate this population (in person, video consultation, via RN instruction, etc) all due to expose risks, PPE conservation needs, etc will remain facility dependent. Many facilities have taken to designating a COVID team, creating a schedule which allows patient care in other areas of the hospital to be accomplished prior to seeing COVID patients or designating a unit/area of the facility for COVID patients. Many COVID+ patients will receive a clinical bedside swallow evaluation however an objective swallow evaluation may be deferred due to policy changes in patient transport, PPE or cleaning procedures.

ASHA and the AMA- Otolaryngology and Radiology sections have developed guidelines related to AGPs (Aerosol Generating Procedures).  Aspects of evaluation and treatment of dysphagia such as FEES, MBSS, portions of the clinical bedside swallow evaluation and treatment techniques are considered aerosol generating procedures.

• Tracheostomy/ Ventilator:

Q: How can I help establish a tracheostomy management team at my facility?

A: This requires a lengthy answer! First make sure that your knowledge is sufficient to lead or help initiate a tracheostomy team (consider your years of experience, exposure to variety of diagnoses requiring tracheostomy, knowledge of tracheostomy tube types and facility/surgeon preference, etc). Consider what is the primary need for the tracheostomized population at your facility (patient discharge training/education needs, trach trouble shooting, pathway to decannulation). You may also need to consider the SLP relation with the surgical services performing tracheotomies and the relation with the respiratory therapy team. Once you have all the background information and your “why,” take your thoughts to your immediate manager as you will likely require support in pursuing a hospital wide effort. Identify key team members such as respiratory therapists knowledgeable in tracheostomy management, nurses, case managers, and a physician “champion” (someone who can influence needed change in practice management/policy). Once key team members have been identified consider additional items such as: roles of each team member, rounding (structure and frequency), creation of education items (written pamphlets, videos, etc), discharge and follow up care, templates for (electronic) documentation and even options for new MD orders for tracheostomy team management. There are several publications that support effectiveness of a tracheostomy team. Here are a few to get you started:

Ncbi.nlm.nih.gov/pmc/articles/PMC4751971/

https://pubs.asha.org/doi/abs/10.1044/persp3.SIG13.89

Q: What is the SLP role in tracheostomy management?

A: This is likely facility dependent, however offering your skillset is important as changes in voice/communication options and swallowing function are possible experiences of the tracheostomized patient. I would encourage you to learn about the tracheostomy products at your facility and preferences of differing surgical teams (OMFS- Oral Maxillofacial Facial Surgery vs ENT- Ear Nose Throat vs General Surgery for example). Many facilities have the respiratory therapy team vs the SLP team as the primary evaluating service or some facilities utilize a team approach. When evaluating swallow function and communication of a tracheostomized patient, you will need to understand the patients’ primary etiology, why the patient required a tracheostomy tube (ventilator weaning, upper airway obstruction, tracheal abnormalities, etc) and what the medical goal is (not all patients are candidates for decannulation). Have a mental checklist of items you will chart review for and assess at bedside- type and configuration of tracheostomy tube, ventilator dependency vs active weaning vs trach collar oxygen and what the oxygen requirement is, current respiratory treatments, secretion management (both oropharyngeal and tracheal),  tolerance of cuff deflation if the patient is still with a cuffed product, voice production with finger occlusion, need/readiness/benefit of a speaking valve and/or cap. The majority of tracheostomized patients who are exhibiting signs/symptoms of dysphagia will require an objective exam (just like non-tracheostomized patients). It is important to note that not all tracheostomized patients will experience dysphagia, however pending their medical etiology, it is always a possibility especially in the acute phase of illness. Making recommendations such as downsizing the tracheostomy tube size or exchanging to a cuffless tracheostomy tube are appropriate recommendations by the SLP if these recommendations facilitate improved voicing/tolerance of a speaking valve/ thus potential improvement in swallow function. Be clear in your documentation and tie your recommendation to a speech related goal.

Q: What are the steps toward tracheostomy decannulation?

A: First, establish that decannulation is part of the medical goals and is medically warranted at the time. The SLP will not be the one to decannulate the patient however we can be involved in decision making and capping trials. The patients’ dysphagia severity (if oral intake is possible), secretion management, respiratory status (including pulmonary toileting), voice/communication status and tracheostomy product type for weaning are top considerations for the SLP, however additional considerations to be mindful of include orofacial swelling from recent surgery, possibility of near future surgeries, need for ventilation at night (ex. obstructive sleep apnea) to name a few examples. Your documentation should include the patient’s tolerance of prolonged finger occlusion, speaking valve tolerance, and what the criteria for “tolerance” is- vocal quality, oxygen saturation, respiratory rate, etc. It is important to be as objective as possible when describing the patient response during treatment sessions leading up to recommendation for decannulation.

Q: What is a typical work schedule in an acute care hospital?

A: While the day-to-day hours of your shift may change slightly, most therapists working in the acute setting will be required to work some (or many) weekends and holidays. Some hospitals use an on-call system for weekends and holidays.

Q: What type of caseload should I expect to treat in an acute hospital setting?

A: In most acute care hospitals, you will have a highly diverse caseload with many medical etiologies, especially for therapists working in teaching hospitals/county hospitals/ level I trauma centers/ stroke centers, etc. The size of the therapy team is likely directly proportional to the volume/ census of the hospital. Some larger hospitals may have 10-20 speech therapists, while smaller community hospitals may have 1-5 speech therapists or use PRN (per diem) therapists instead of hiring full time staff.

Q: How long do you treat patients during their acute hospital stay?

A: This is highly variable based on the complexity of the patient, their anticipated medical needs impacting their length of stay and the progress the patient makes. Some patients may be on caseload for weeks on end while others are in/out of the hospital in just a few days. Many patients may need an evaluation by the speech therapist but may not require treatment during the acute stay (or at all), so your caseload can turn over quickly. Each session with the patient will vary in treatment length pending on patient needs, caseload volume and competing priorities.

• ADULT OUTPATIENT SETTING:

Q: What are the hours worked by an outpatient SLP?

A: Each outpatient facility will vary in what they consider full time and part time status. Generally, a full time SLP can expect to work between 30-40 hours a week and a part time SLP can expect to work less than 30 hours. Again, this is dependent upon the facility. Most outpatient facilities are open Monday-Friday and will observe holidays.

Q: What does a typical case load look like in an outpatient setting?

A: In an adult outpatient clinic, a large majority of the cases will be neurological in nature. These patients will present with language or cognitive related deficits. An SLP in this setting should be prepared to use a wide range of their skill sets as they will also likely encounter patients presenting with dysphagia, voice and fluency deficits, and motor speech disorders.

Q: How does the referral process work in outpatient speech pathology?

A: Patients are typically referred to SLP services by a physician or other agency such as Veterans Affairs. Patients may self-refer if they are planning on paying out of pocket for services.

Q: What are some positives to working at an outpatient setting?

A: Working in an outpatient setting has many positives. More often than not, an outpatient SLP will have their own space to treat. A lovely office, all to yourself! This differs from acute and inpatient settings where SLPs will generally treat in the patient’s rooms or in the communal treatment gym. Having an enclosed space allows for more privacy for the patient and allows the clinician to control the amount of distractions present in environment. Other positives of working in the outpatient setting are that SLPs get to work with a variety of populations, and have the opportunity build good relationships with patients and their families. Lastly, an outpatient setting usually harbors a team environment where an SLP will get to work closely with other disciplines.

Q: What are some cons to working at an outpatient setting?

A: In another answer it was stated that that a positive to working in an outpatient setting is that an SLP will typically have their own office to treat in. Well this can be both a blessing and a curse. If they are busy, an outpatient SLP can expect to spend most of their day alone in the office treating patients. Someone who enjoys frequent socialization and change may prefer another setting. As compared to an acute or inpatient setting (where physicians are in house), an outpatient setting may bring on challenges keeping fluid communication with physicians. It can get frustrating making frequent phone calls to a physician’s office to obtain orders for a patient.

Q: What are some areas of training or continuing education I should receive if I plan to work in an outpatient facility?

A: It is important to diversify your skillset so that you will have advanced skills in variety of areas. For example, in the area of dysphagia, it might be in your best interest to get training on how to interpret instrumental exams (MBSS/FEES) and how to incorporate current technologies (Neuromuscular Electrical Stimulation, Surface Electromyography) into your treatment. In other areas of practice, it would be important to gain knowledge on current evidence-based treatment models. Information on popular and effective treatment modalities/interventions can often be obtained by asking other SLPs or sifting through SLP related social media content.

Q: Are there any board certifications that would be beneficial to me as an outpatient SLP?

A: A Board-Certified Specialist is an SLP who has completed the Clinical Specialty Certification (CSC) program in a specific area of clinical practice. Currently, there are four specialty areas that are recognized by ASHA. Each are individually monitored by a Specialty Certification Board (SCB). Each Board sets the educational, clinical, and experiential standards to obtain your BCS, which are then approved by ASHA’s Council for Clinical Certification Committee (CFCC) on Clinical Specialty Certification. Below, you can find the names of the three SLP-relevant certifications. Each certification comes with varying requirements that can be found on their respective board’s websites:

American Board of Child Language and Language Disorders

American Board of Fluency and Fluency Disorders

American Board of Swallowing and Swallowing Disorders

• PEDIATRIC HOME HEALTH SETTING:

Q: What is the required productivity for home health SLPs?   

A:  Each home health company sets its own requirements, but 26-30 visits per week is common.  ST visits typically last 30-45 minutes.  Therapists and families are encouraged to make up any missed visits (due to illness, vacation, family schedule, etc…) in order to meet the prescription that was determined at the evaluation.  Most SLPs provide treatment Monday-Thursday and utilize Friday to complete evaluations and make-up visits.

Q: What is the drive time/mileage like for home health therapists? 

A:  This depends upon your treating territory.  Some therapists prefer to treat in the town/county in which they live.  Others prefer to drive to nearby towns/counties and do not mind the extra mileage.  Reputable companies will pay therapists’ mileage and/or offer a company car.  It is not uncommon for mileage after a full day of treatment to be around 100.

Q: Does Home Health therapy have to be provided only in the home? 

A:  Home Health therapy supports the child in their daily environment.  Therapy very often is provided in the child’s home, or the home of other family members.  But it can also take place in a daycare, a local park, or even a fast-food restaurant (which is great for carryover, especially with feeding and AAC skills!)  It is important to note that creditable home health companies will never require their therapists to enter a home where they feel unsafe. 

Q: When and how do Home Health therapists do their documentation?  

A: Documentation is typically completed via an EMR (electronic medical record) designed for therapy. Some EMRs require an internet connection for documentation, but others allow documentation offline that can later be synced to the child’s EMR chart.  Some therapists prefer to do their documentation at home, at the end of the day or the end of the week.  Others document during a break for lunch or in their car between sessions. 

Q: What therapy materials does a pediatric home health SLP need? 

A:  Many home health therapists provide therapy using the child’s own toys/books.  This allows for easy parent demonstration and facilitates carryover because the parent can model what the SLP has taught using the same materials. Additionally, using the child’s own toys/books minimizes the transmission of germs that may be transferred from home to home.  However, some families have limited resources or do not know what is developmentally appropriate and stimulating for their child.  In these cases, therapists may wish to create materials specially for the child (using resources such as Boardmaker, Lessonpix, Teachers Pay Teachers, or other sources).  It may also be appropriate for the therapist to have a collection of books, cause/effect toys, turn-taking games/toys, puzzles, building toys (blocks, Legos), and open-ended toys (such as vehicles, play food, a farm set, play dough, bubbles, potato head, dinosaurs, and/or a doll with accessories).

• PEDIATRIC OUTPATIENT SETTING:

Q: What is the required productivity for SLPs in an outpatient clinic?

A: Productivity varies depending on the site. You may need to book above required targets to account for cancellations or no shows.

Q: Do I get paid a salary or per visit?

A: This will vary greatly with which outpatient clinic/setting you choose to work. Some pay hourly with the expectation that you will carry a full caseload each day. You may be requested to consolidate your schedule if you have cancelations etc. and adjust your hours. Some clinics who pay hourly may pay you for documentation time. Other clinics will pay per visit with no additional pay for documentation time. Some clinics pay a salary for employees who do not clock in or out but are expected to maintain a high level of productivity. When there are no patients to see, program building, projects, and the development of plans of care is expected.

Q: Will I have documentation time built into my schedule?

A: The short answer is “no”. Documentation can be tricky but there are ways to make it effective, timely, and efficient especially when the facility has a time frame when documentation is due.

1. If your Electronic Medical Records program allows, pre-chart for evaluations and treatment during available time prior to the appointment.
2. Bring your computer into the session and document parental concerns, progress made etc. while the parent/caregiver communicates these at the beginning of the session.
3. Take 5 minutes at the end of the session while you are discussing home program to document what the parent/caregiver is to work on before the next visit.
4. Document during no shows, cancelations etc.
5. Documentation across all settings is one of the main concerns for most therapists. Each Therapist needs to find a system that works for them within their setting. Though the steps you are taking to plug in your documentation may seem “small”, the “mountain” of notes at the end of the day will be greatly affected by it!

Q: What are the opportunities to collaborate with other disciplines and/or mentors?

A: Most companies, especially outpatient clinics, will establish monthly staff meetings or collaborative discharge planning meetings to keep those difficult and complex kiddos moving in a fruitful direction. These are so helpful for goal planning as it helps each discipline understand core/common goals for the patient. One of the other great things about the outpatient clinic is the opportunity to learn from other clinicians! When there is a cancellation or the company provides you with time for personal/clinical development, mentors are easily accessible, and much learning can take place!

• NICU SETTING:

Q: What is the primary role of a speech pathologist in the NICU?

A: The typical primary role of a SLP in NICU is to provide individualized plans of care in regards to feeding and swallowing to guide and protect neuromotor development.  We also provide ongoing education for families and staff on the most up to date evidenced-based practice.  To consistently ensure positive outcomes we also participate in quality improvement projects.  Last but certainly not least, we also provide treatment and education for infants who require care long-term.  We address speech and language goals to ensure developmental milestones are met and/or there are minimal to no delays in development.

 

Q: How can I become a speech therapist practicing in the NICU?

A: Because the positions are not plentiful, it is a more difficult setting to break into.  Just as in acute care with adults, working your way to a more complex and fragile population is always a good idea.  There are many specific continuing education courses designed for the potential NICU therapist and the current NICU therapist.  Attend these and show that you are willing to do the work to learn a field that is not explicitly taught in graduate school!  Find a mentor that is willing to allow you to observe and ask questions.  Read current literature and find as many normal babies as you can and observe them.  As I tell my graduate students constantly, know what is NORMAL so you can identify and target what is NOT NORMAL!

 

Q: Are there any special certifications that you need to have?

A: No.  You don’t NEED one.  However, according to the Neonatal Therapy National Certification Board, a therapist in the NICU is actually a Neonatal Therapist.  You can become a Certified Neonatal Therapist after applying for and passing an exam.  In order to qualify, you must have years of experience in the NICU setting and continuing education hours.  Once you pass, you become a CNT (Certified Neonatal Therapist) whose focus is on developmental care and considering and supporting a fragile infant in all aspects of their sensory and motor systems.  Since feeding is a primary focus for a speech therapist, taking continuing education specifically designed to support mothers and babies at the breast is highly recommended.  There are many lactation certifications to choose from.  A Certified Lactation Counselor (CLC), Certified Lactation Educator (CLE), or becoming an International Board-Certified Lactation Consultant (IBCLC) may be potential options.

 

Q: What does a typical treatment session look like in NICU?

A: Babies in the NICU are typically “touched” every 3 hours.  This design is to allow us to cluster their care so they can get much needed rest to grow and develop.  Their feedings are given every 3 hours.  If they are showing signs that they are ready to feed, they are offered the breast if mom is present, or a bottle.  The SLP may help with the baby’s care such as changing a diaper or taking a temperature so they can evaluate the baby’s readiness.  If they are ready, the SLP then evaluates the baby’s sucking pattern (the maturity of their suck swallow and breathe sequence), their fluid expression (how well they can get milk from the particular nipple they are being fed with), fluid management (if there are any signs or symptoms of aspiration), and their endurance (how much energy they have to be able to support oral motor skill development).  Vitals such as heart rate, respiratory rate, the infant’s work of breathing, and their saturations are also constantly being monitored before, during, and after the feeding.  The SLP will then provide recommendations for the best nipple or flow rate, the best position, and what other supports the infant might need to improve their feeding and oral motor skill development.

 

Q: What are some of the advantages and challenges of working in the NICU?

A: The advantages are plentiful as are the challenges.  However, being able to come alongside a family to help them nourish (not just feed) their baby is incredibly rewarding.  That may look like getting a baby skin to skin for the first time, helping a mama breastfeed the first time, providing education to families on all the things the baby is doing on their own when they are feeling so helpless since they are now not the “expert” on their child, and loving and snuggling sweet babies, of course!  The challenges are also plentiful.  Many NICUs across the world have developed practices that are not necessarily developmentally centered.  Because medical staff personnel may not understand, “old school cultures” may be perpetuated.  Creating relationships to affect change is something many NICU therapists will bond over.  It is a constant challenge.  Also, while many babies have such positive outcomes, there are some who will live only a short while.  These families hold pieces of your heart, and emotionally, it can be taxing.