Marianne McGrath – Facts from the frontline
Preparing for the first wave of COVID-19 was not an easy task. Guidance seemed to change on a daily basis as the NHS came to grips with an ever-evolving pandemic.
Redeployment and PPE caused considerable difficulties in the everyday lives of SLTs. In addition, as this was a new cohort of patients with no evidence to refer to, it was challenging to give patients and families a dysphagia prognosis related to COVID-19.
I work at Chelsea and Westminster Hospital and our trust experienced a significant volume of COVID-19 admissions. Within the speech and language therapy team, we felt it was important to retrospectively analyse the caseload in order to reflect and prepare for a second wave.
Our data analysis included patients admitted to ITU with confirmed COVID-19 between March and June 2020.
In total, 74 patients were admitted with the disease: 54 were successfully discharged and 20 passed away. Of the 54 patients that survived, 20 were referred to speech and language therapy during their ITU admission.
Of these 20 patients, four were female (two of whom were pregnant) and 16 were male. Three of the patients had strokes while in ITU.
All of the patients had been intubated and 18 of the 20 patients had a tracheostomy. No patients required a long-term tracheostomy though, and all of these patients were decannulated before being stepped down to the acute wards.
All patients referred to speech and language therapy had an initial swallow assessment and required modified fluid and diet recommendations. A quarter of the patients required swallow rehabilitation and four of these patients were deemed to require a percutaneous endoscopic gastrostomy (PEG). All patients who had dysphagia rehabilitation and a PEG were male.
Patients were followed up by SLTs when they were stepped down to acute wards. Seven were discharged to other hospitals or rehabilitation units, and all four patients who had a PEG were discharged from hospital with the PEG. They had all commenced oral intake but could not meet their nutrition or hydration needs orally. Six patients were discharged from hospital with ongoing speech and language therapy needs.
Positively, 14 of the patients were discharged from hospital on their baseline recommendations, suggesting that COVID-19 does not result in long-term swallow impairments in the majority of patients. It would be beneficial to follow all patient journeys after discharge to monitor the long lasting effects of COVID-19 on the swallow function.
Analysing trends between the 20 patients who were referred to speech and language therapy, the majority of patients presented with critical care weakness, resulting in globalised oropharyngeal dysphagia.
Swallow function improved as generalised strength improved and these patients got back to their baseline recommendations in 1-2 weeks post-decannulation.
There were trends for patients who presented with a more significant dysphagia and required more intense speech and language therapy input and monitoring. This included multiple failed extubation attempts, a slow tracheostomy wean (>4 weeks), and cognitive impairments.
Interestingly, there was a high element of patient anxiety and fear of choking/aspiration noted, which often halted fluid and diet upgrades.
Through this experience and analysis, we learnt that the speech and language therapy service could prepare for adequate staffing numbers to deal with a second wave. This may also help to build a case when there is a risk of staff members being redeployed.
The data reveals a need for appropriate training to ensure there are enough tracheostomy trained SLTs. It also allows SLTs some insights in terms of dysphagia presentation in COVID-19, as well as the prognosis and potential risk factors that would result in patients requiring more extensive SLT input.