Covid-land-The sequel: Navigating the bridge from acute care to LTACH

Co-author: George Barnes MS CCC-SLP

In my previous blog post, entitled “COVID-land, NYC: Reflections from the front lines”, I discussed how my institution and SLP department were managing COVID-19 cases. Prior to that post, my SLP colleague across the river in New Jersey, George Barnes, wrote about COVID-19 practice management considerations in “Are we essential? Personal essay from the epicenter.”

I mentioned that things here in New York City seem to change in what feels like the blink of an eye. Well, I blinked- and as of today, my hospital now has over 100 tracheostomized COVID-19 patients.

George and I wanted to again share our experience from COVID-land, specifically, regarding tracheostomized patients- from both the acute care and LTACH perspective. We hope to open the door for conversation, provide insight, and… foresight.

SLP ACUTE CARE (Talia)

We entered the conversation

Our institution chose not to trach patients early given considerations for aerosol generating procedures (AGP), increased infectious risk, and unclear benefits of performing early tracheostomy from available data. When the conversation about performing tracheostomies on the hundreds of intubated patients in our ICUs began, SLP entered immediately. We discussed the rationale, candidates, timing, and SLP’s role.

• We agreed with the benefits: to reduce risk for laryngeal injury with prolonged intubation, reduce sedation-related delirium, progress toward vent-weaning, reduce ICU length of stay, and facilitate quicker rehabilitation efforts.
• Patients considered were those for whom recovery was expected but prolonged mechanical ventilation was anticipated, and ideally patients with only respiratory failure and other organ systems intact.
• Timing of tracheostomy was to be determined on a case by case basis with consideration for overall prognosis and likelihood of decreased/low viral load.
• We discussed the SLP’s role, current limitations in our practice, suctioning, HMEs, PMVs, and AGPs!
• SLP had one request: consider a #6 Shiley trach when able, instead of an 8!

We joined the SWAT team

A “Trach SWAT team” was formed to respond to post-trach care issues (I have to credit ENT for that tactical name- we are fighting an invisible terrorist!). The multidisciplinary team consists of members from the surgical teams, an MD/PA, respiratory therapy, SLP, and nurse management.

In anticipation of a large volume of patients and post-trach care concerns, the SWAT team collaborated on a number of efforts including:

• Prioritizing safety of healthcare workers: signs on every door to alert caregivers to tracheostomy status and prompt caregivers to don appropriate PPE.
• Providing caregiver awareness: signs to provide information about when the trach was placed, the size, by whom, and guidelines for next inner cannula change. Additional signs alert caregivers to Passy Muir Valve precautions.
• Educating medical teams: A trach guide on emergency indications to call the SWAT team, trach care guidelines, considerations for vent weaning, and when to consult SLP.

Reducing aerosolization: This is an ongoing effort to try to “close the system” and reduce aerosolization potential for patients that have weaned off the ventilator (but cannot yet tolerate a PMV). So what’s the answer?

• HMEs have been appropriate for some, but not all- due to secretion burden and risk for mucous plugging.
• The SWAT team and respiratory therapists’ arsenal has included a number of configurations such as: An in-line suction port with t-piece trach tubing and HEPA filters, and a trach collar covered by a face tent which is connected to suction instead of additional oxygen.
• The answer right now seems to be: “If you can’t close it, contain it” (can’t take credit for that one either), but I will add: “in whatever way possible!”

We developed guidelines for timing of SLP intervention

Here is where I suspect the most variability in SLP practice management may lie.

• Trach-to-vent patients: Pre-COVID-19 era, we frequently worked with RT to provide early cuff deflation, in-line speaking valves, and start dysphagia therapy. We are not doing this with COVID-19 patients. There is too little known about the risks involved, and in all honesty- we simply lack the manpower.  To be clear, we didn’t abandon these patients: SLP developed special trach-friendly communication boards for nursing and physicians to use with appropriate patients.
• Trach-collar patients: We requested the following: 1) Cuff deflation be completed by the medical team, and 2) Consultation for a speaking valve and clinical swallow evaluation be placed when the patient demonstrated tolerance of trach collar for at least 6 hours over 2 days or 12+ continuous hours. We acknowledged this was arbitrary, but hoped to ensure respiratory stability.

We are now weathering this new storm!

Familiar questions now arise: How are we managing? How are these COVID-19 trach patients faring?

Passy Muir Speaking Valve (PMV) Assessment

• What’s different from pre-COVID-19 era? We now have to understand any unique oxygen/HME configurations we see, and anticipate what may need to change after PMV placement (this has been coordinated with respiratory therapy). Oftentimes we are using the valve directly for trial instead of digital occlusion. We are hyper aware of our PPE use and positioning during evaluations to maintain our safety.
• Some patients have surprised us with immediate PMV tolerance. Secretion burden or impaired mental status has remained a barrier to use for others.
• We communicate with the SWAT team daily about which patients are tolerating a PMV continuously and may be ready for capping trials and future decannulation.

Swallow Evaluation

• To be honest, this caused a few grey hairs, but we had to act fast despite so many unknowns: Were COVID-19 trach patients any different than non-COVID-19 trachs? Could we use the same clinical bedside skillset we relied upon for post-extubation patients? Could we use PO trials tinged green with food coloring, acknowledging this method’s limitations?  Could we push the envelope for younger patients with no comorbidities? Or did we need to complete an MBSS on every case given risk for silent aspiration?
• To date, we have completed MBSS studies on patients that have demonstrated tolerance of continuous PMV use and did well with green-tinted PO trials at the bedside. All have resumed oral diets, with a handful requiring modified consistencies. They are typically the last cases of the day in radiology to allow for proper room sanitation.
• We have elected now to manage some select cases clinically, but continue MBSS if there are any concerns. We have also completed FEES sparingly/when medically necessary, and only after the patient has tested COVID negative (via 2 negative PCR swabs and 1 negative tracheal aspirate), as body habitus and deconditioning have presented challenges with mobilization.
• It is case by case. We are using clinical judgement, critical thinking skills, and communicating with medical teams- as we have always done. 

Patient Trends

• As expected, there are none! There has been great variability in age, medical history, hospital course, and presentation. We have seen some patients with very linear progression to swallow success and decannulation. Rehabilitation efforts from physical and occupational therapy colleagues have been paramount to moving patients forward.
• Others have remained vent-dependent, received PEGs, and have been discharged to LTACHs.

As more information is learned, processes are trialed, and data is collected – the hope is to continue to optimize COVID-19 trach patient management in the acute care setting. But for some patients, the journey doesn’t stop there…

SLP LONG-TERM ACUTE CARE (George)

The Set-Up

The LTACH I work in is now a designated COVID-19 critical care center for patients transitioned from acute care. In order to manage the internal spread of the virus, we have three separate units: 1) COVID-19 positive, 2) COVID-19 recovered, and 3) COVID-19 negative. After admission, patients are re-tested regularly to see if they can be moved to the recovery side. One of the most difficult challenges has been staffing the COVID-19 positive unit, especially with our trach/vent population. Those with medical concerns/certain comorbidities are not entering the unit. Our hospital has managed with a combination of flexibility, extra staffing, proper PPE, and good old fashioned bravery. Staff with increased medical risks treat our negative and/or recovered patients.

The Team

The importance of close collaboration with my colleagues has never been clearer, especially with the many fast moving parts in our COVID-19 trach patients’ recovery. SLP is working closely with the RNs, CNAs, physicians, pulmonologists, respiratory therapists, and dieticians. Mutual respect and appreciation for each others’ expertise has only grown.

The Process

I have elected not to interfere during the vent-weaning process and have been able to wait until the patient is off the ventilator before initiating SLP intervention. My involvement with vent-dependent patients has been limited to facilitating non-verbal communication. I have seen relatively timely weaning from the vent to a non-aerosol generating (NAG) device- different than the usual trach collar set-up. My LTACH’s strategy to reduce aerosolization is by using a supplemental O2 device that is essentially an unusual looking t-piece with a viral filter on one end, an HME on the other, and a ballard in-line suction catheter in the middle. Getting used to the new set up NAG’d me for a while (pun intended!), but containing the virus certainly outweighs any cons.

The Trends

The majority of COVID-19 trach patients I have worked with so far have been alert, motivated, improving every day, and… anxious to go home! Suboptimal mentation is often a major barrier to progress  in acute care. A huge silver lining for many patients at this point in their medical course is that they can follow directions and are cognitively intact. 

SLP Intervention

Approximately 2/3 of my patients have hit the ground running with a speaking valve and ice chips.

• After demonstrating speaking valve tolerance: these patients are capped for a few days then decannulated.
• We have acknowledged the risk for silent aspiration: however instrumental studies are on hold. Thus, we have made efforts to optimize the patient presentation by waiting until we have a “closed system.” Full diets are usually only initiated via clinical bedside evaluation after capping and/or decannulation.
• The blue dye test is discouraged in our facility, mostly due to its well known shortfalls- but we have learned to be flexible in this crisis and are using it on a case by case basis to detect gross aspiration.

For the other 1/3 of my patients, the picture is a little fuzzier

• Some patients are more debilitated due to complications during their hospital course such as CVAs or critical illness myopathy.  They are slower to recover and present with generalized weakness and fatigue, poor phonation, a weak cough, and copious secretions. Many already have a PEG.
• Secretion burden has been the biggest barrier to speaking valve/PO candidacy. Mucolytics such as mucomyst were previously used to treat secretions, but are now considered too aerosolizing. The scopolamine patch, while typically used infrequently due to over-thickening secretions, has shown positive results in a small sample of patients.
• For select cases who are stable and alert, we have been liberal with utilizing ice chips. Small amounts can be recommended to begin exercising the oropharynx and encourage swallowing to improve secretion management.

The Recovery

Many of the trach patients I am seeing were in the hospital for weeks to months. Though the trends are still being tracked- so far the results are promising! Compared to our typical, highly complex and medically-involved patients who require prolonged rehabilitation- we have seen significant progress and recovery in many of our COVID-19 trach patients.

Conclusion

Along the continuum of care, COVID-19 trach patients are being managed thoughtfully and skillfully- albeit differently, but with promising outcomes! SLP at our respective facilities are all, hands on deck.

However, as George mentioned in one of his @dysphagiadude Instagram posts- when it comes to COVID-19, what is relevant this week might not be the next. At the time some of you may read this, our practice management may have already changed. Or perhaps for other readers- your institution is managing cases differently and you have thoughts or ideas to share?  If that is the case- welcome to the conversation!

Be sure to visit George Barnes on Social Media @dysphagiadude

Co-author Biography: George Barnes MS CCC-SLP has clinical experience in a variety of settings including acute care, acute rehab, skilled nursing and long term acute care. This variety has developed his specialization in dysphagia management with a focus on diagnostics through instrumental swallow evaluations. His concentration is on geriatric patients with complex medical status. He is the co-founder of FEESible Swallow Solutions, a mobile speech pathology company dedicated to improving access to high quality dysphagia services for patients in the skilled nursing setting. He has a track record of supporting the field of speech pathology by paying his knowledge forward to other professionals via graduate level education, clinical fellowship and student supervision, the Student to Empowered Professional (STEP) mentorship program, ASHA special interest groups, peer review for ASHA course material, the SIG13 dysphagia editorial committee, and participation in various interdisciplinary teams and committees in the hospital setting. He is a multiple ASHA ACE Award recipient for his dedication to continuing education. George actively conducts and supports new research aimed to improve efficiency and accuracy in dysphagia diagnostics, management, and care.