Introduction

Speech-language pathologists (SLP) that work in the acute care setting are accustomed to critical thinking and working in an ever-changing environment. Typically, these SLP’s are members of the care team for patients who are critically ill. Counseling critically ill patients and their families is often second nature to these SLPs. However, no amount of collaboration with a palliative care team, continuing education credits on counseling, or graduate education courses could have prepared these SLPs for the moral and ethical dilemmas they face today during the COVID-19 pandemic. SLPs are now required to advocate, educate, communicate, and research best practices more than ever before.

Patient Joe

Patient Joe is in his eighties with a history of multiple medical co-morbidities. He has dementia, and removal from his familiar environment induces increased confusion and agitation. Joe presented to the hospital in respiratory failure and required mechanical ventilation for one week due to COVID pneumonia. Joe is extubated but is now requiring restraints and medication for his anxiety and agitation. The medical team consults the SLP to evaluate Joe’s swallow function. After a thorough chart review, the SLP performs the clinical bedside swallow evaluation. Joe demonstrates clinical indicators of aspiration at the bedside and will require instrumentation that the facility does not allow in patients who are COVID+. The SLP calls Joe’s wife, who has been his life partner for 60 years. Joe’s wife begins to cry because she cannot visit him, and she knows that he is extremely confused in the hospital. Joe’s wife states that Joe has essential medication to take by mouth for one of his health conditions. 

What will the SLP do?

COVID-19 Impact

The global pandemic has impacted the entire healthcare industry and exacerbated issues present before the pandemic in many facilities. Hospitals worldwide have re-allocated resources (Bonalumi et al., 2020) and increased productivity requirements for employees. This has resulted in increased emotional burnout and turnover at many facilities (Penwell-Waines et al., 2018). Individuals are also experiencing compassion fatigue and demonstrating a lack of empathy when caring for critically ill patients (Shreffler et al., 2020). Marginalized communities have also been significantly affected by the COVID-19 pandemic. Marginalized communities are defined as individuals who are excluded from mainstream society due to differing race, gender identity, sexual orientation, socioeconomic status, age, physical ability, language, and immigration status (Sevelius et al., 2020). Members of these communities have increased susceptibility to COVID-19 due to inadequate living conditions, the inability to social distance, and lack of access to quality medical care. Speech-language pathologists are experiencing these issues in all facets, in addition to profession-specific problems. These problems include a lack of access to imaging due to hospital administration rules, increased need for personal protective equipment access, and difficulty navigating the evaluation and treatment plan without families present in-person. To achieve progress for patients and families experiencing fear like never before, SLPs must advocate, educate, communicate, and research because the lives of patients and the future of the profession depend on it. 

Advocacy

SLPs are advocates for these patients to receive the same care as their COVID negative counterparts. The respiratory component of this disease is contributing to an increased length of time on mechanical ventilation for critically-ill patients, and in many cases, tracheostomy placement. The prevalence of silent aspiration in these patient populations is well-known and has been documented heavily in the literature. Barker et al. (2009) found that greater than 50% of patients with post-extubation dysphagia were intubated for over 48 hours. Hernandez et al. (2020) conducted a study on the respiratory status and supplementation requirements in 231 COVID-19 critically ill patients in the intensive care unit. 24% of those patients required mechanical ventilation for over 24 hours. SLPs have observed these patients requiring increased oxygen and mechanical ventilation dependency.

To avoid conducting instrumental examinations due to aerosol generation procedure (AGP) risk, some institutions have supported thickening liquids and performing compensatory maneuvers at the bedside without objective imaging. Evidence refutes the use of this practice as thickened liquids are more often silently aspirated than thin consistencies at the bedside (Miles et al., 2018). Additionally, emerging evidence indicates that AGP risk does not increase with the presence of endoscopy or videofluoroscopy, indicating a similar prevalence of AGP in these studies and clinical bedside swallow evaluations (Kay et al., 2020). Advocacy for these instrumentals to continue in the safest possible manner must occur to serve patients best.

Education and Communication

To slow the spread of infection, hospitals have prohibited visitation in patients with COVID-19. The lack of family presence in patients with baseline cognitive-communication deficits or new onset of intensive care delirium may exacerbate these individuals’ confusion. Effective communication between the patient and family can reduce confusion related to acute hospital admission (Eghbali-Babadi et al., 2017). Speech-language pathologists can improve patient satisfaction and contribute to the reduction of hospital-associated delirium through:

  • Routine phone calls to the family, keeping them involved in treatment planning and decision making.
  • Facetiming family members in the patients’ room.
  • Reading cards and letters from the family to the patient to provide encouragement.

Although SLPs can only speak to the speech pathology plan of care, SLPs can encourage other care team members to call and talk to the family. Participating in multidisciplinary intensive care unit rounds can improve communication between disciplines and promote family communication/education. The SLP must also be present during family phone calls to give updated information on the speech pathology plan of care. Education and communication of this nature take increased time, which may mean that the SLP cannot see as many patients in a day as before. Because of this necessary collaboration with the patients’ families who cannot be present, SLPs must advocate for decreasing productivity loads and increasing staffing. 

Research

As with any unknown territory, SLPs must turn to the literature to support practice patterns. Understanding where to find evidence-based information, and the process for critically appraising the evidence is crucial. The American-Speech-Language-Hearing Association has developed an evidence-based practice toolkit to aid in the process of answering clinical questions. Finding mentors grounded in the literature may also help the SLPs feel comradery in these ethical and moral dilemmas. Through ASHA and independent organizations, online forums may connect professionals with other individuals who can provide support and education to clinicians fighting these pandemic-associated battles. The profession improves when collaboration and encouragement between professionals occurs. 

A Final word about Joe

Appropriate management of Joe includes:

  • Advocacy for instrumentation
  • Collaboration with Joe’s wife on the evaluation and treatment plan
  • Facetiming with Joe’s wife in his room
  • Attending multidisciplinary rounds to advocate for Joe
  • Researching the best possible methods of managing Joe’s dysphagia and cognitive-communication deficits

If you are reading this article, you have likely evaluated and treated a patient like Joe. A knowledgeable advocate that demonstrates empathy and love for patients like Joe can help shine a light during the dark times we are currently facing.

References

Barker, J., Martino, R., Reichardt, B., Hickey, E. J., & Ralph-Edwards, A. (2009). Incidence and impact of dysphagia in patients receiving prolonged endotracheal intubation after cardiac surgery. Canadian Journal of Surgery, 52(2), 119–124. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2663495/

Bonalumi, G., di Mauro, M., Garatti, A., Barili, F., Gerosa, G., & Parolari, A. (2020). The COVID-19 outbreak and its impact on hospitals in Italy: the model of cardiac surgery. European Journal of Cardio-Thoracic Surgery : Official Journal of the European Association for Cardio-Thoracic Surgery. https://doi.org/10.1093/ejcts/ezaa151

Eghbali-Babadi, M., Shokrollahi, N., & Mehrabi, T. (2017). Effect of Family–Patient Communication on the Incidence of Delirium in Hospitalized Patients in Cardiovascular Surgery ICU. Iranian Journal of Nursing and Midwifery Research, 22(4), 327–331. https://doi.org/10.4103/1735-9066.212985

Evidence-Based Practice Toolkit. (n.d.). American Speech-Language-Hearing Association. Retrieved December 6, 2020, from /research/ebp/evidence-based-practice-toolkit/

Hernandez-Romieu, A. C., Adelman, M. W., Hockstein, M. A., Robichaux, C. J., Edwards, J. A., Fazio, J. C., Blum, J. M., Jabaley, C. S., Caridi-Scheible, M., Martin, G. S., Murphy, D. J., & Auld, S. C. (2020). Timing of Intubation and Mortality Among Critically Ill Coronavirus Disease 2019 Patients: A Single-Center Cohort Study. Critical Care Medicine. https://doi.org/10.1097/CCM.0000000000004600

Kay, J. K., Parsel, S. M., Marsh, J. J., McWhorter, A. J., & Friedlander, P. L. (2020). Risk of SARS-CoV-2 Transmission During Flexible Laryngoscopy: A Systematic Review. JAMA Otolaryngology–Head & Neck Surgery, 146(9), 851–856. https://doi.org/10.1001/jamaoto.2020.1973

Miles, A., McFarlane, M., Scott, S., & Hunting, A. (2018). Cough response to aspiration in thin and thick fluids during FEES in hospitalized inpatients. International Journal of Language & Communication Disorders, 53(5), 909–918. https://doi.org/10.1111/1460-6984.12401

Penwell-Waines, L., Ward, W., Kirkpatrick, H., Smith, P., & Abouljoud, M. (2018). Perspectives on Healthcare Provider Well-Being: Looking Back, Moving Forward. Journal of Clinical Psychology in Medical Settings, 25(3), 295–304. https://doi.org/10.1007/s10880-018-9541-3

Shreffler, J., Petrey, J., & Huecker, M. (2020). The Impact of COVID-19 on Healthcare Worker Wellness: A Scoping Review. Western Journal of Emergency Medicine, 21(5), 1059–1066. https://doi.org/10.5811/westjem.2020.7.48684

Sevelius, J. M., Gutierrez-Mock, L., Zamudio-Haas, S., McCree, B., Ngo, A., Jackson, A., Clynes, C., Venegas, L., Salinas, A., Herrera, C., Stein, E., Operario, D., & Gamarel, K. (2020). Research with Marginalized Communities: Challenges to Continuity During the COVID-19 Pandemic. AIDS and Behavior, 1–4. https://doi.org/10.1007/s10461-020-02920-3

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Rebecca Brown, M.S.,CCC-SLP,CNT
Rebecca is the Lead Inpatient Speech-Language Pathologist at CHRISTUS Good Shepherd Medical Center and primary SLP in the neonatal intensive care unit. Rebecca is responsible for the evaluation and treatment of medically complex neonates, adults, and geriatric patients in the ICU. She develops policies, procedures, and all of her team's education. Rebecca is an adjunct instructor at two universities and is completing her Ph.D. in Health Sciences at Rocky Mountain University of Health Professions with a Neuro Rehab concentration. Rebecca serves on various committees at the local, state, and national level, including ASHA SIG 13 Professional Development Committee, TSHA Medical Executive Committee, IDDSI Task Force, and the Diversity & Inclusion Committee at Stephen F. Austin State University. Rebecca is a volunteer with Feeding Matters, Dysphagia Outreach Project, and National Foundation of Swallowing Disorders. Rebecca is on the board of a local non-profit dedicated to the provision of education and resources for expectant parents.

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