Position paper

Speech and language therapy in adult

critical care

For review: 2018

2014
The Royal College of Speech and Language Therapists
2 White Hart Yard
London SE1 1NX
020 7378 1200
www.rcslt.org

CONTENTS
1.

Key recommendations for implementation............................................................ 3

2.

Introduction ..................................................................................................... 4

3.

Objective of the Guideline .................................................................................. 5

4.

Definition ......................................................................................................... 5

5.

Aetiology ......................................................................................................... 6

6.

Demographics .................................................................................................. 7

7.

Philosophy of Care ............................................................................................ 8

8.

National Context ............................................................................................... 8

9.

The Role of the Speech and Language Therapist ................................................... 9

10. The Benefits of Providing a Speech and Language Therapy Service ....................... 10
10.1 Communication............................................................................................... 10
10.2 Swallowing disorders (dysphagia) ..................................................................... 11
11. the Risks of Not Providing a Speech and Language Therapy Service ...................... 12
11.1 Communication disorders ................................................................................. 12
11.2 Swallowing disorders (dysphagia) ..................................................................... 14
12. Medico-legal issues ......................................................................................... 16
13. Workforce Development and Planning ................................................................ 17
14. Further Information ......................................................................................... 18
15. Bibliography ................................................................................................... 19
16. Development group ......................................................................................... 24
17. Acknowledgements ......................................................................................... 25

RCSLT position paper: Speech and language therapy in adult critical care

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1. KEY RECOMMENDATIONS FOR IMPLEMENTATION

Through their detailed knowledge of communication and swallowing,

speech and language therapists (SLTs) have a vital role in optimising the
care, experience and outcome of patients on critical care.

All people with critical care needs who have communication and/or
swallowing difficulties due to organic, concomitant or psychogenic
disorders should have access to an early, timely, responsive and
appropriately skilled speech and language therapy service.

Commissioners should ensure that speech and language therapy services

are incorporated in critical care service planning and development.
Therefore, speech and language therapy services should be examined to
ensure they are appropriately resourced and skilled to provide quality care
for people with critical care needs throughout the patients pathway,
including appropriate provision after discharge from ICU (National
Institute for Health and Clinical Excellence: Rehabilitation after critical
illness, hereafter referred to as NIHCE CG 83.) This would include funding
for appropriate speech and language therapy staffing and equipment e.g.
communication aids.

Speech and language therapy services should provide equal access to

intervention for both communication and swallowing difficulties dependent
on clinical need.

Organisations should develop critical care competency programmes for

speech and language therapy staff and ensure staff are appropriately
trained and competent American Speech and Hearing Association (ASHA,
2009).

Speech and language therapy services need to engage in continuous

appraisal of service provision and quality via clinical audit or research e.g.
auditing unmet need.

Speech and language therapy services for people with critical care needs
should be provided within an integrated multidisciplinary context to
ensure the philosophy and goals of intervention are shared and
consistent.

Communication and swallowing are the responsibility of the whole team

the role of the SLT is to empower and educate others as well as providing
direct specialist input.

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2. INTRODUCTION
The roles of health professionals who work in the field of critical care are often
overlooked, underestimated and under resourced. Key professions in the critical
care setting include .speech and language therapy (Quality Critical Care,
2005). The NIHCE CG 83 (2009) states: Rehabilitation for general critical care
adult patients should be delivered by appropriate members of a multidisciplinary
team (for example therapists). The Royal College of Speech and Language
Therapists (RCSLT) supports these reports and believes that any person with
critical care needs with communication or swallowing difficulties has a right to
access a professional with expertise in these areas. Research has shown that
there is a risk of undiagnosed dysphagia in the critical care population (Macht,
2011). Therefore there is a need for speech and language therapy intervention
as part of a multidisciplinary team (MDT) approach to manage this risk to
improve patient outcomes. SLTs, through their role in some MDT environments,
may enhance patient outcomes although more research is needed to determine
the specific effects of speech and language therapy (Speed and Harding, 2012).
Despite the original RCSLT critical care position paper being written in 2006, the
current situation of speech and language therapy provision for people with
critical care needs in the UK is inequitable, with the majority of services not
specifically funded for this client group (Ward et al, 2012).
This position paper highlights the speech and language therapy provision that
should be available to ensure equity of access for people with critical care needs,
and the key role that SLTs should have within critical care teams. These speech
and language therapy services should be adequately planned and resourced,
based on local demography and user need and the required speech and
language therapy skill mix.
This paper is intended to advise and generate discussion between commissioners
and service providers regarding the provision of speech and language therapy
services that meet the requirements of people with critical care needs, their
families, carers and other professionals in line with national policies across the
UK.
Communication and swallowing difficulties cause considerable distress in
critically ill people. The following are quotes from service users:
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
Adult, South London
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 person in critical care, South Manchester

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3. OBJECTIVE OF GUIDELINE
People with critical care needs who have difficulty with communication and/or
swallowing require access to an early, timely, responsive, appropriately skilled
speech and language therapy service to maximise their choice, participation,
safety and wellbeing.
The purpose of this document is to provide SLTs with the most up to date
evidence to support the provision of speech and language therapy services in
critical care in order to improve patient outcomes.

4. DEFINITION
This position statement refers to people who are in hospital and who have critical
care needs. Critical care refers to the level of care given to a group of people
who are deemed to be critically ill. Many people who are critically ill have
requirements for support for their neurological, medical, respiratory and
digestive systems, all of which can impact on their ability to communicate and
swallow independently.
The classification system set up by Comprehensive Critical Care was revised by
the Intensive Care Society in 2009 and provides a helpful framework as follows:
Level 0
Requires hospitalisation
Needs can be met through normal ward care
Level 1
Patients recently discharged from a higher level of care
Patients in need of additional monitoring/clinical interventions, clinical input or
advice
Patients requiring critical care outreach service support
Level 2
Patients needing pre-operative optimisation
Patients needing extended postoperative care
Patients stepping down to Level 2 care from Level 3
Patients receiving single organ support
Basic respiratory support [>50% FiO2]
Basic cardiovascular support
Renal, Neurological, Dermatological or Hepatic support singly
Level 3
Patients receiving advanced respiratory support alone or a minimum of two
organs supported
Patients receiving advanced cardiovascular support

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Technologies to prolong life/enable clinical management of people who are

critically ill may include mechanical ventilation (invasive or non-invasive),
tracheostomy tubes, nasogastric tubes and endotracheal airways. The presence
of these can also impact on communication and oropharyngeal swallowing
abilities.
5. AETIOLOGY
While the focus of critical care is on levels of care rather than location, some
patients require care in specialist ICUs such as neuroscience, cardiothoracic or
burns. Many of these patients will require speech and language therapy input
due to specific conditions which increase their risk of swallowing and
communication problems. Patients exhibit a range of aetiologies (neurogenic or
structural, e.g. unilateral vocal fold palsy following thoracic surgery or inhalation
burns to the larynx). These patients often have complex swallowing and
communication difficulties of multiple aetiologies. More generally, critical care
patients are at risk of swallowing and communication problems as a result of
muscle weakness, prolonged intubation and procedures such as tracheostomy
(NIHCE CG 83).
Some patients may also have difficulty in swallowing and communication as a
result of muscle weakness, prolonged intubation or procedures such as
tracheostomy. The prevalence of swallowing dysfunction after extubation has
been reported in between 20% and 83% of patients intubated for longer than 48
hours (Leder et al, 1998; Tolep et al, 1996; Skoretz et al, 2010; Heffner 2010,
NIHCE CG 83).
There are three main causes of communication and/or oropharyngeal swallowing
disorders in critical care patients:
Organic communication or oropharyngeal swallowing disorders, such as
those caused by stroke, major trauma, head injury, Guillian Barre
syndrome, post-surgery to the oral cavity/pharynx or larynx, chronic
obstructive pulmonary disorder (Martin-Harris-B 2001), Adult Respiratory
Distress Syndrome (ARDS), spinal cord injury, tumours, etc.
Concomitant communication or oropharyngeal swallowing disorders, such
as the effects of critical care neuropathy (due to disuse atrophy of striated
muscle) or the effects of technologies to prolong life/enable clinical
management of the illness such as mechanical ventilation, tracheostomy
tubes, nasogastric tubes and naso-pharyngeal airways (Conlan and Kopec
2000; Pannunzio 1996).
Psychogenic communication or oropharyngeal swallowing disorders, such
as those resulting from critical care psychosis, delirium or clinical
depression.
In addition, within the ICU environment an undervaluing of communication can
occur due to the level of arousal and medications (Hemsley et al, 2001).
Mechanically-ventilated people report high levels of frustration when
communicating their needs (Patak et al, 2004).

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6. DEMOGRAPHICS
Approximately 18.5% of hospitalised people require treatment in a critical care
environment (Level 1-3) (North West London Critical Care network critical illness
audit, 2003). Recent data presented at the 2011 UK Intensive Care Society
Conference reported a current provision of 3,747 critical care beds across 156
ICUs with admissions increasing year on year. In 1996 there were 85,000
admissions rising to 120,000 in the year 2000, and 201,000 in 2009.
Importantly, admission of 80+ year olds has doubled between 1996 and 2009,
to 1,700. This is due to a combination of factors such as people living longer,
improvements in healthcare technologies and raised expectations of survival.
Tracheostomies are also increasingly commonplace. Recent work undertaken in
the North West of England (McGrath, National Tracheostomy Safety Project
2013) extrapolating from HES statistics, has estimated approximately 15,000
percutaneous tracheostomies are managed in Englands critical care units
annually. The implications of this, along with the growing critical care population,
are an increasing demand for speech and language therapy in order to meet
swallowing and communication needs.
The literature reports a high range (50-76%) of aspiration in the critical care
population (Elpern et al, 1987; DeVita and Spierer-Rundback, 1990; Elpern et al
1994; Tolep et al, 1996; Leder, 2002; Gross et al, 2003; Toniolo and Soneghet,
2007; Barker et al, 2008; Hafner et al, 2008). The prevalence of swallowing
dysfunction after extubation has been reported in between 20-83% of patients
intubated for longer than 48 hours (Leder et al, 1998; Tolep et al, 1996). In
particular, aspiration can frequently be seen in people requiring prolonged
ventilation of three or more weeks (Elpern et al, 1994; Tolep et al, 1996; Leder,
2002). Long duration of mechanical ventilation was independently associated
with postextubation dysphagia and the development of postextubation
dysphagia has been independently associated with poor patient outcomes
(Macht, 2011). There is a greater impact of aspiration in this vulnerable group,
e.g. reduced mobility, reduced arousal, possible reduced awareness or cognitive
impairment.
However, there have been numerous difficulties in trying to establish the true
prevalence and incidence of aspiration in the mechanically-ventilated population.
The main reason for this is that aspiration is identified in different ways in
different studies. Some studies employ bedside assessments (Elpern et al, 1987)
and others use instrumental techniques (Leder, 2002; Gross et al, 2003). In the
studies that have employed instrumental techniques it is reported that aspiration
can be silent or covert. This questions the veracity of those studies that have
relied on overt aspiration detection; indeed, the true incidence of aspiration
could be higher than is reported.
The prevalence of communication difficulties in this population is reported to be
between 16-24% (Thomas and Rodriguez, 2011). The inability to speak and the
associated communication difficulties that result are a major source of stress for
people who are or have been intubated (Menzel, 1998).

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Cognitive impairment (which could include critical care psychosis) may impact on
patients awareness of dysphagia and impact on functional recovery as patients
are unable to modify their behaviour to reduce risks (Parker et al, 2004).
7. PHILOSOPHY OF CARE
NIHCE CG 83 emphasises patient-centred care which takes into account
patients individual needs to allow patients to reach informed decisions about
their care.
Many people who are critically ill have full decision-making capacity and should
have access to the same level of services and choices offered to less critically-ill
people in hospital. People who are critically ill have the right to maintain optimal
use of their current communication and swallowing functions. Patients who do
not have full decision-making capacity additionally have the right to have
communication skills supported to optimise their capacity and the right to access
Best Interest processes in the informed absence of capacity.
Speech and language therapists have the specialist skills to assess an
individual's capacity to communicate and understand information and to
facilitate optimal communication. The SLT is the person best qualified to advise
on the most effective means of presenting information and choices to the person
in critical care with a significant communication disorder. This facilitates the
persons participation in their own care and decision-making process by
maximising opportunity to exert free choice. This is a particularly important role
for SLTs in relation to current legislation such as the Adults with Incapacity Act
2000 (Scotland), the Mental Capacity Act 2005 (England and Wales), and the
Human Rights Act 1998.
The critical care context itself indicates the need for a flexible approach to
service delivery, which reflects the limited windows of opportunity for speech
and language therapy intervention. The intensity of the environment lends itself
to a model of care, which can be labour intensive and requires extensive multidisciplinary collaboration.

8. NATIONAL CONTEXT
The specific value of speech and language therapy within the critical care setting
has been highlighted in a number of national documents. The latest policy
documents which relate to the provision of critical care services across the UK
can be found in the link on the RCSLT website (www.rcslt.org).
The NIHCE CG 83 states that: Rehabilitation for general critical care adult
patients should be delivered by appropriate members of a multidisciplinary team
(for example therapists).
In November 2010, a number of professional bodies (including Intensive Care
Society (ICS), National Patient Safety Agency (NPSA), Difficult Airway Society,
ENT UK, and RCSLT) endorsed the National Tracheostomy Safety Project which
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produced an information resource for the safer management of patients with

tracheostomies and laryngectomies (www.tracheostomy.org.uk). This document
states the need for a speech and language therapy assessment for patients who
cannot swallow safely.
Currently, there is no agreed national guidance regarding the minimum staffing
levels for speech and language therapy services in ICUs. It is acknowledged that
this issue needs addressing and requires both a benchmarking exercise to
establish current speech and language therapy ICU services and development of
subsequent guidelines on best practice staffing levels. Consequently, the gap
between the current and desired service levels remains unclear but it is
recognised that local variation exists and is dependent upon the available
resources and skills, recognition of the speech and language therapy role and
type of ICU.
9. THE ROLE OF THE SPEECH AND LANGUAGE THERAPIST
Speech and language therapists have clinical expertise in the areas of
assessment and management of communication and swallowing difficulties,
whether they arise due to the nature of the underlying medical conditions, due
to concomitant conditions, or due to the presence of equipment/technologies to
support life. They are therefore integral to the critical care MDT and provide
specialist knowledge and skills, which all people with complex communication or
swallowing difficulties should be entitled to access (Baumgartner, 2008; Braine
and Sweby, 2006; Batty, 2009).
The role of the SLT in critical care is to work as an integral part of the MDT to:

Use specialist skills to inform differential diagnosis regarding the nature

and cause of communication and swallowing difficulties, including higher
level cognitive-linguistic difficulties/cognitive difficulties and disorders of
consciousness.

Carry out specialised instrumental methods of assessment for swallowing

difficulties such as fibreoptic endoscopic evaluation of swallowing (FEES)
and videofluoroscopy, where appropriate.

Provide specific communication and swallowing rehabilitation, goals,

programmes, equipment and advice to optimise and maintain function, in
liaison with the MDT.

Reduce the impact of the communication and/or swallowing difficulty

throughout the persons journey from the hospital stay and into primary
care (Quality Critical Care Beyond Comprehensive Critical Care, 2005),
by providing support, education, advice and advocacy to the person,
carers and MDT.

Provide training to the MDT and carers regarding communication and

swallowing difficulties, such as screening and managing non-complex
difficulties.

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Assess and manage swallowing and communication in ventilatordependent and tracheostomised patients, contributing to the MDT
assessment of weaning and ability to safely swallow oropharyngeal
secretions.

Identify communication and swallowing difficulties that may impact on the

patients ability to function in their normal environment, and support
appropriate discharge destination planning and referral to rehabilitation,
should this be required (including patients with higher level cognitive
communication difficulties).

Carry out clinical audit and engage in collaborative research (e.g. user
experience) and evaluate outcomes of therapy.

Speech and language therapists should understand and work within the specific
demands of the different environments. They will be influenced by facilities and
resources available, client needs, speciality skills of other team members, local
policies and procedures. Speech and language therapists with specialist skills
working within the field also have a role to provide training and support to other
SLTs who are developing skills or services to critically ill people.
10.

THE BENEFITS OF PROVIDING A SPEECH AND LANGUAGE THERAPY

SERVICE

10.1 Communication
Speech and language therapists can facilitate a persons participation, choice
and satisfaction with treatment and recovery within the critical care setting by
providing:

Early identification, differential diagnosis and expected trajectory of

communication difficulties, caused by or co-existing with the use of
tracheostomy or mechanical ventilation.

Specialist, individualised treatment/advice/strategies for the person to

maximise communication ability, including interventions to increase
patient engagement, choice and user experience (including use of cuff
deflation, speaking valves, capping off, and specialist tubes to facilitate
communication in the presence of a tracheostomy tube).

Specialist advice/strategies to family members and MDT staff to minimise

communication difficulties between the person and others.

Facilitation of capacity assessments.

Screening assessment of laryngeal injuries, dysphonia and concomitant

conditions that may require further referral for clinical specialist upper
airway investigations (e.g. ENT assessment or videostroboscopy).

Alternative communication devices (both low and high tech) where

appropriate, to facilitate/augment communication.
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Speech and language therapists have specialist skills in developing

communication with even the most severely-impaired people. They can offer
assessments in communication with low and high tech aids, communication with
ventilator adaptations (Tippett and Siebens, 1991; Hoit and Banzett, 1997),
speaking valve/tube assessments (including Passy Muir) and modification of
environment and switch controls for people with very limited dexterity. Speech
and language therapists can contribute to the teams management of the
ongoing and changing needs of these people (Grossbach et al, 2011).
They have specialist skills in assessing comprehension of language and
language-based, higher-level cognitive communication skills, both of which are
crucial components in ascertaining a persons capacity to engage in consent
discussions regarding their treatment and complex ethical decisions. They are
also skilled in facilitation of communication to enable people to participate in
consent discussions. This role is clearly delineated in the Adults with Incapacity
Act 2000 (Scotland) (Code of Practice 2002), which states: "A number of
defining characteristics of incapacity clearly relate to communication skills, such
as comprehension and expressive skills. Although many health and social care
professionals have an awareness and training in human communication, clinical
psychologists and speech and language therapists have a specialist knowledge
and expertise. Where doubt exists, available expertise should be called upon to
help medical practitioners and others who may require assistance in assessing a
person's capacity."
By providing timely, ongoing assessment and intervention, and providing
effective communication strategies and/or aids, there may be a reduction in the
negative emotional responses (such as fear, anxiety, frustration) and an
improvement in the psychological wellbeing of the person, family and staff
(Manzano et al, 1993; Dikeman and Kazandjian, 2003).
By restoring or facilitating communication the person may participate more
readily in treatment and provide valuable feedback on clinical issues, such as
work of breathing, which can often be the clinicians greatest diagnostic tool
(Isaki and Hoit, 1997; Spremulli, 2005).
10.2 Swallowing disorders (dysphagia)
It is well documented and recognised that prompt intervention in the
management of dysphagia can prevent costly and life-threatening complications,
such as aspiration pneumonia (Barquist and Leder, 2002). Odderson (1995)
showed that the incidence of aspiration pneumonia due to dysphagia could be
reduced from 6.7% to 0% through effective management.
Speech and language therapists can minimise preventable secondary respiratory
and nutritional complications of swallowing difficulties, which arise from or coexist with use of tracheostomy/ventilator, by providing:

Specialist evaluation of swallow function, which may include instrumental

assessment using FEES or videofluoroscopy (McGowan et al 2007; Hales
et al 2008; Intensive Care Society Standards 4.7 2008).

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Information to the MDT on early identification of dysphagia and

swallowing status, aetiology and prognosis, enabling informed decisionmaking regarding tracheostomy/ventilator weaning and commencement
and timing of oral intake and including postural advice for optimal
swallowing function, the consistency of food, fluid and medication and
methods of alternative feeding.

Specialist advice and assessment in situations where the patient is noncompliant, risk managed/palliatively managed.

Specialist individualised treatment, advice and strategies to maximise and

rehabilitate swallowing abilities, including interventions to promote quality
of life and psychological wellbeing (Segaran, 2006).

Specialist advice on strategies for management of oral hygiene and oral

secretions where people are dysphagic and/or where there is a
requirement for oral desensitisation, e.g. the management of bite reflex.
This may include early intervention to reduce the occurrence of
complications, such as hypersensitivity, at a later stage and may include
sensory integration approaches such as Facial Oral Tract Therapy
(F.O.T.T.) (Gilmore et al, 2003). Also stimulation of both sensory and
motor components of the cerebral swallowing system (Lowell et al, 2008).

Specialist weaning interventions which may reduce the time taken to wean
from the tracheostomy/ventilator and may potentially reduce the length of
stay in critical care and possible complications of long-term trache
(Thompson and Ward et al, 1999; ICS standards 7.1 2008).

11.

THE RISKS OF NOT PROVIDING A SPEECH AND LANGUAGE

THERAPY SERVICE

11.1 Communication disorders

11.1.1
Clinical risk: Frustration of critically ill person and staff with
ineffective means of communication.
Establishing communication for critically ill people is largely overlooked in most
critical care settings. At best, units may provide communication boards or rely
upon attempting to lip read. Both of these options can be time consuming and
frustrating, leading to significant fatigue for the already-fatigued person
(Albarran, 1991). Loss of speech whilst a tracheostomy is in place could cause
great distress to the patient even if the patient is warned beforehand (National
Tracheotomy Safety Project 2013). Nurses often report feeling frustrated and
incompetent when they are unable to understand and meet peoples needs
(Bergbom-Engberg and Haljamae, 1989).
11.1.2
Clinical risk: Inability to communicate effectively regarding clinical
needs, such as pain or to convey consent or opinions regarding treatment and
hospital management.
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Many people in ICU describe feelings of disempowerment and social isolation due
to their inability to communicate effectively and because they are unable to
express how they feel (Hemsley et al, 2001). Studies that look at the impact of
having communication difficulties in a critical care environment report that
anxiety, fear, insecurity and inability to sleep are all associated with being
unable to speak (Menzel, 1994). A study by Bergbom-Engberg et al (1989)
involving 158 people who had been treated with a respirator found that inability
to talk and communicate was the dominant reason for anxiety and/or fear during
their treatment. It is assumed that communication problems only affect the
person during the intubation period. However, there is evidence that, even after
discharge from hospital, the psychological wellbeing of many people is affected.
This often relates to communication difficulties experienced during their stay in
critical care (Hemsley, 2001).
11.1.3
Clinical risk: Increased length of stay in intensive care beds due to
inability to participate in goal setting, clinical treatment and end of life
decisions.
Numerous studies have explored the length of stay in intensive care beds related
to lack of participation in goal setting, clinical treatment and end of life
decisions. Poor communication between the person who is critically ill and the
physician, difficulties ascertaining the persons capacity for informed consent and
a failure to understand their preferences were seen to contribute to length of
stay in intensive care settings, particularly for those receiving longer-term
interventions (Dowdy et al, 1998). Teno et al (2000) reported that among
patients who spent 14 or more days on an ICU, a substantial majority had not
talked with their physicians about their preferences or prognoses. Lilly et al
(2000) reported that more than 50% of patient days were spent providing
advanced supportive technology for patients that did not survive. Increased
communication with people about their values and preferences particularly
related to end-of-life decisions were positively correlated with reduced length of
stay (due to pro-active decisions regarding acceptance of palliative care) within
the critical care environment (Dowdy et al, 1998). Hemsley et al (2001) state
that having severe communication impairment could affect the length of stay
for a patient as negative mood would impact on the patients recovery or reduce
the patients ability to participate effectively in therapy.
11.1.4
Clinical risk: Undiagnosed laryngeal injuries and concomitant voice
disorders.
Lundy et al (1998) described a range of laryngeal injuries frequently resulting in
communication disorders following decannulation from both short- and longterm endotracheal intubation. Positive correlations were also made between
laryngeal injuries and the presence of a nasogastric tube; however, it was
unclear if this was purely related to the presence of the tube or that people
requiring enteral feeding were generally intubated longer term.
11.1.5
11.1.6

Clinical risk: Compromised psychosocial wellbeing.

Clinical risk: Lack of reliable outcome measures.

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Menzel (1997 and 1998) demonstrated that self-esteem of people in an ICU who
were unable to speak was significantly associated with the persons emotional
responses. Lack of communication can have a significant impact on psychosocial
and emotional wellbeing of the person and affect reliable measurement of
outcomes. These types of measures, especially those looking at psychosocial
factors, tend to be verbally dependant. If the person is unable to communicate,
results will be skewed.
11.2 Swallowing disorders (dysphagia)
11.2.1
stay.

Clinical risk: Aspiration pneumonia, including increased length of

It is recognised that if the complex interrelationship between eating, swallowing

and breathing is disrupted by the presence of assistive ventilatory technologies,
then impairment in swallowing can result (Nishino et al, 1989; Dikeman and
Kazandjian 2003). Speech and language therapists can help to manage these
difficulties by providing specialist skills in the assessment, diagnosis and
management of the dysphagia. It is well documented and recognised that
prompt intervention in the management of dysphagia can prevent costly and life
threatening complications such as aspiration pneumonia. Aspiration is the
leading cause of pneumonia in the ICU and contributes significantly to the
overall morbidity and mortality of the critically ill patient (McClave et al 2002).
This complication can cause significantly longer hospital stays, thus increasing
the cost of care (Carter-Young et al, 1990; Romero et al, 2010). Odderson
(1995) stated that people with aspiration pneumonia stayed in hospital on
average 5.5 days longer.
11.2.2

Clinical risk: Compromised nutrition and hydration.

In Nutrition Support Guidance developed by the National Institute for Health and
Clinical Excellence (2006), malnutrition has been linked to impaired wound
healing, reduced muscle strength and fatigue, poor cough pressure, predisposing
to and delaying recovery from chest infections and increased length of hospital
stay: In critically ill patients, malnutrition is associated with impaired immune
function, impaired ventilatory drive and weakened respiratory muscles, leading
to prolonged ventilatory dependence and increased infectious morbidity and
mortality. Malnutrition is prevalent in people on ICUs and has been reported as
being as high as 40% (Heyland et al, 2003). Comparative studies of critically ill
people have indicated that there is a significant reduction in infectious
complications if nutrition is delivered via the gut (enteral nutrition) (Heyland et
al, 2003). However, aspiration is the most serious side effect of enteral tube
feeding and has been shown to have a frequency of 40% in patients receiving
enteral tube feeding (McClave et al, 2002).
11.2.3

Clinical risk: Disuse atrophy.

Evidence indicates that between 20% and 83% of patients who have prolonged
intubation with an endotracheal or a tracheostomy tube have swallowing
disorders, predisposing them to aspiration (Leder et al, 1998; Tolep et al, 1996;
Skoretz et al, 2010; Heffner, 2010). These swallowing deficits may be secondary
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to disuse muscle atrophy as reduced swallow frequency and reliance on non-oral

feeding result in less activation of the swallowing muscles, resulting in a weak
and uncoordinated swallow response (DeVita and Spierer-Rundback, 1990;
Burkhead, Sapienza and Rosenbek, 2007). Dikeman and Kazandjian (2003) also
document how decreased base of tongue movement may occur as a result of
continuous pressure by the endotracheal tube placed for mechanical ventilation.
This effect begins on day one of intubation and impacts on swallowing (de
Larminat et al, 1995). The tongue may become deconditioned but this may be
amenable to indirect therapy e.g. oromotor exercises. In addition, people who
are ventilator-dependent and tracheostomised may develop dysphagia as a
result of disuse atrophy and desensitisation and these effects accumulate over
time (Davis and Thompson Stanton, 2004). Speech and language therapists
have a vital role in assisting with the recognition, assessment and rehabilitation
of these problems.
11.2.4

Clinical risk: Prevention of weaning.

Factors preventing weaning from mechanical ventilation and artificial airway

include determining if the person has an inadequate cough and swallow and if
they are systemically unwell e.g. due to pulmonary infection (Intensive Care
Society Weaning Guideline). Aspiration pneumonia therefore impacts on
ventilator status and may physically debilitate a person interrupting the weaning
process (Dikeman and Kazandjian 2003). Delayed weaning, as a result of
inadequate swallowing and risk of aspiration, is a common problem and is also
associated with increased mortality and cost implications (Sheerson 1997). By
assessing swallowing, SLTs can advise on ways to minimise the risks of
aspiration and contribute to the effective weaning process.
11.2.5

Clinical risk: Identification of complications of intubation.

There is controversy in the literature in the last 30 years as to the real effect of
a tracheostomy and endotracheal tube on laryngeal protective mechanisms and
laryngeal injuries, which may cause or contribute to dysphagia and aspiration.
More recently, dysphagia is primarily thought to originate from the patients
medical diagnosis, with the presence of a tube possibly having a contributory
rather than causative effect. (Buckwater et al, 1984; Larminat et al, 1995;
Sasaki et al, 1977; Shaker et al, 1995; Leder and Ross, 2009). Endotracheal
intubation has also been closely linked with the presence of dysphagia and
aspiration particularly in the immediate post extubation period (Ajemian et al,
2001; Barquist et al, 2001; Leder et al, 2002; Solh et al, 2003; Skortez et al,
2010). Sohl (2003) reported aspiration in 52% of elderly critically-ill patients
post extubation with delayed resolution of swallowing impairment and
recommended consideration of FEES for those with impaired preadmission
functional status.
Speech and language therapists contribute to the assessment of swallow
parameters which guide the contributory/causative decision and impact of these
on patient management.

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12.

MEDICO-LEGAL ISSUES

It is not within the scope of this document to discuss at length the medico-legal
issues associated with professional practice. The reader is directed to the
following documents covering this area:

Communicating Quality 3 (2006)

Health and Care Professions Council (HCPC): Managing fitness to practise
(2006)
HCPC: Continuing fitness to practise (2008)
White paper Trust, assurance and safety The regulation of Health
Professionals in the 21st Century, 2007
Department of Health, Practitioners with Special Interests 2003

However, as in all professional areas, the individual SLTs right to practise in the
area of critical care is governed by the regulations of the HCPC. The role of the
HCPC is to safeguard the health and wellbeing of people who use the services of
the professionals registered with them. The HCPC maintains a register of health
professionals who meet the standards for training, professional skills, behaviour
and health. (Your guide to our standards for CPD, HCPC May 2006). Adherence
to the HCPCs codes of practice is the professional responsibility of the individual
therapist.
When an AHP is employed by an NHS organisation, that organisation has
vicarious liability for the AHPs actions. This is in addition to the AHPs
professional accountability to the HCPC (Department of Health, Practitioners
with Special Interests).
The RCSLT is the professional body for SLTs. It provides leadership so that
issues concerning the profession are reflected in public policy and people with
communication, eating, drinking or swallowing difficulties receive optimum care
(Communicating Quality 3: 4.1.1).
It is the responsibility of the individual SLT to provide evidence-based services
that anticipate and respond to the needs of individuals who experience speech,
language, communication or swallowing difficulties (Communicating Quality 3:
1.1).
Additionally, RCSLT provides an insurance policy that indemnifies all its
practising members in the UK, Channel Islands and the Isle of Man. This covers
proven liability arising from alleged professional negligence, breach of
professional conduct and damage to property (Communicating Quality 3:
4.1.4).

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13.

WORKFORCE DEVELOPMENT AND PLANNING

The appropriate speech and language therapy skill mix must be provided and
reviewed to meet the needs of people receiving care for critical illness regardless
of the setting. However, it is not currently possible to recommend a notional
caseload figure at an individual or service level. This is due to difficulties in
establishing accurate prevalence and incidence data and regional variation in
critical care service structure (see section 6).
The configuration of the speech and language therapy service will be different
depending on the skill mix, local environment, health economy, staffing,
resources and levels of expertise. One model of provision of care is where the
skill mix exists across the speech and language therapy service, since many
skills are transferable from one area of current clinical practice to another e.g.
communication aid assessments, bedside swallowing assessment, voice
management. Another model could be where highly-specialised clinicians provide
speech and language therapy services. Clinical and or service leaders should
carry out regular appraisal of skill mix in order to address fluctuations and
changes in service needs. It is recommended that a systematic review of service
planning and succession planning be regularly undertaken.
It is the responsibility of the SLT with expertise in critical care to share
knowledge and expertise with speech and language therapy colleagues within
the service and throughout local/regional networks/hubs e.g. RCSLT e-group,
Clinical Excellence Networks, Journal Clubs, Allied Health Professional (AHP)
networks, mentoring, critical care networks, clinical supervision, RCSLT advisors.
It is recommended that SLTs routinely collaborate with other disciplines on
training, development, audit and research, such as respiratory physiotherapists,
critical care nurses, and anaesthetists.
There should be local discussion and negotiation regarding multidisciplinary role
boundaries and associated competencies e.g. suctioning, initial cuff deflation
assessment, provision of low tech augmentative and alternative communication
and screening of communication/swallowing disorders.
The RCSLT critical care working group has developed a Knowledge and Skills
Framework (KSF) to act as a guide for clinical/technical skill development for
SLTs developing skills in tracheostomy and critical care (these are available to
RCSLT members through the RCSLT website). The KSF competency document is
designed to elaborate only clinical skills that are specific to critical care and
therefore does not encompass more generic skills that may be incorporated in an
individual clinicians KSF outline. Therefore, this document is designed to have
relevant sub-sections incorporated into individuals overall KSF framework. It is
recommended that managers consider using the framework to develop KSF
outlines for a range of clinical staff grades from SLT assistant and newly qualified
therapists to principal therapists to ensure SLTs are appropriately trained and
competent (ASHA 2009).

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14.

FURTHER INFORMATION

This document complements several other publications, which are outlined

below:
Clinical Guidelines (2003). The guidelines contain recommendations that are
explicit statements providing specific clinical guidance on the assessment and
management of each clinical area. Each recommendation is supported by
evidence from the literature or is based upon the consensus of clinical experts.
Communicating Quality 3 (2006). Standards and guidelines that represent
the benchmarks of speech and language therapy practice and provide criteria
against which compliance can be judged.
RCSLT Workforce Project (2006). Describes how SLTs work and how they
are key to delivering priorities in service delivery, such as reducing waiting times
and achieving health targets in the current NHS environment: www.rcslt.org
Kelly AM, Hydes K, McLaughlin C and Wallace S. (2007) Fibreoptic
endoscopic evaluation of swallowing (FEES): The role of speech and
language therapy. RCSLT Policy Statement
Position paper on videofluoroscopy (RCSLT 2006) Currently under revision.
Guidelines for the development of local standards of oral health care for
dependent, dysphagic, critically and terminally ill patients. (2000) British
Society for Disability & Oral Health: http://www.bsdh.org.uk/
Department of Health. Practitioners with Special Interests. November
2003 Implementing a scheme for Allied Health Professionals with Special
Interests. London: http://www.dh.gov.uk/assetRoot/04/06/16/11/04061611.pdf
HPC: Managing fitness to practise. HCPC February 2006: http://www.hpcuk.org/assets/documents/10001344Managingfitnesstopractise.pdf

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16.

DEVELOPMENT GROUP

An expert panel was convened by the RCSLT to write this revised position paper
(first paper written 2006).
Members of the RCSLT critical care working group (revision 2012):
Mrs Lynne Clark, RCSLT advisor, Acute Specialist SLT, Kings College Hospital,
London
Mrs Gemma Jones, Clinical Lead SLT Critical Care, Royal Free Hospital, London
Ms Aeron Ginnelly, Advanced Specialist SLT Critical Care, St Thomas' Hospital,
London
Mrs Vicky Thorpe, Specialist SLTENT/Dysphagia,
Great Ormond Street Hospital NHS Foundation Trust, London
Mrs Sue McGowan, RCSLT adviser, Clinical Specialist SLT, National Hospital for
Neurology and Neurosurgery, London
Mrs Sarah Wallace, RCSLT adviser, Clinical Coordinator in Dysphagia, University
Hospital of South Manchester NHS Foundation Trust, Manchester
Mrs Sarah Haynes, Head of Speech and Language Therapy, The Royal Hospital
for Neuro-disability, Putney

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17.

ACKNOWLEDGEMENTS

This final document is the result of extensive consultation within and beyond the
SLT profession. The authors would like to acknowledge the contribution of
Tracheostomy Clinical Excellence Network (Specific Interest Group) and RCSLT
Dysphagia Advisors in commenting on the draft versions of this document.

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