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Introduction

Here you will find best practice guidance for speech and language therapists (SLTs) working in critical care. 

For related RCSLT topics please see Clinical Guidance A-Z

For RCSLT professional guidance see Delivering Quality Services A-Z and Professional Accountability and Autonomy

Please contact us if you have any suggestions or feedback on these pages.

Definitions

Critical care refers to the level of care given to a group of people who are deemed to be critically ill. Critical care provides support and close monitoring for patients with high level needs due to a wide range of medical, surgical or trauma related health issues. Communication and swallowing can be affected by the health issue itself and/or critical care interventions.

Classification system for adults

The classification system set up by Comprehensive Critical Care was revised by the Intensive Care Society in 2009 and provides a helpful framework for adult patients 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 post-operative 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.

Classification system for children

For paediatric patients the levels have been defined by the Paediatric Intensive Care Society’s Quality Standards for the Care of Critically Ill Children (2015):

Level 0

Children who can be cared for on a general children's ward.

Level 1 - Basic critical care

Close monitoring and observation required but not requiring acute mechanical ventilation. Examples would also include: the recently extubated child who is stable and awaiting transfer to a general ward; the child undergoing close post-operative observation with ECG and pulse oximetry and receiving oxygen.

Children requiring long term chronic ventilation (with tracheostomy) are included in this category, as are Continuous Positive Airway Pressure (CPAP) and non-invasive ventilation.

The dependency of a Level 1 patient increases to Level 2 if the child is nursed in a cubicle.

Level 2 - Intermediate critical care

The child requiring continuous nursing supervision who is usually receiving advanced respiratory support, i.e intubated and ventilated or receiving BiPAP.

Also the unstable non-intubated child, for example some cases with acute upper airway obstruction who may be receiving nebulised adrenaline.

The dependency of a Level 2 patient increases to Level 3 if nursed in a cubicle.

Level 3 - Advanced critical care (with 5 sub levels of advanced care need)

The child requiring intensive supervision at all times who needs additional complex therapeutic procedures and nursing. For example, unstable ventilated children on vasoactive drugs and inotropic support or with multiple organ failure.

Children requiring ventilatory support or support of two or more organs systems. Children at Level 3 are usually intubated to assist breathing.

Children requiring the most intensive interventions such as particularly unstable patients, Level 3 patients managed in a cubicle, those on Extra Corporeal Membrane Oxygenation (ECMO), and children undergoing renal replacement therapy.

Classification system for neonatal patients

For neonatal patients, these levels have been defined as:

  • Level 3: Neonatal Intensive Care Unit: NICU for complex care.
  • Level 2: Local Neonatal Unit: LNU for high dependency.
  • Level 1: Special Care Baby Unit: SCBU for initial and short-term care.
  • Level 3 Units may contain all three levels of care.

Please note that Level 3 units may contain all three levels of care.

(Neonatal unit guide, 2019)

You can also find further detailed definitions on the Bliss website and please also refer to RCSLT information on Neonatal care.

Considerations for special populations

Critical care environments cater for a range of conditions or may specialise in specific patient populations that require special consideration for their care.

These considerations may include: a type of surgery or medical intervention carried out, prognosis, medication interactions, psychological status or requirement for hospital transfer, and involve the following patient populations (this list is not exhaustive):

  • adults with complex learning difficulties
  • congenital anomalies
  • neonates
  • paediatrics
  • prolonged disorders of consciousness (PDOC) 

Aetiology

There are several causes of communication and/or oropharyngeal swallowing disorders in critical care patients, including: 

  • neurological impairment
  • mechanical disruption
  • respiratory difficulties
  • psychological problems

These may occur as a result of the following (this list is not exhaustive):

  • acute and progressive neurological disorders
  • acute and chronic respiratory disorders
  • airway management/reconstruction and maxillofacial surgery
  • aurns
  • cardiothoracic surgery
  • chronic lung diseases
  • extracorporeal membrane oxygenation (ECMO)
  • major trauma
  • neurosurgical and neurological disorders
  • mncology/haematological conditions
  • spinal cord injury (SCI)
  • transplant surgery
  • acquired or traumatic brain injury or polytrauma

It is recognised that patients in critical care can also develop difficulties due to the interventions they require, namely:

  • intubation and post-extubation dysphagia
  • drug related impairments, e.g. dry mouth, delirium
  • invasive and noninvasive mechanical ventilation disrupting normal airflow
  • endotracheal, tracheostomy and nasopharyngeal airway tubes
  • nasogastric and gastrostomy feeding tubes
  • critical illness myopathy, neuropathy and myoneuropathy
  • developmental delay or arrested development due to prolonged hospitalisation

Patients may become disoriented in the intensive care environment due to wake/sleep disorders, delirium, psychosis or mood disorders, and these may have an additional impact on their interactions, communication and ability to comply with rehabilitation.

Role of Speech and language therapy

SLTs have a vital role in optimising the care, experience, safety and outcome of patients in critical care.

A minimum staffing level of 0.1 wte SLT per bed is recommended to deliver a service in critical care. This may increase depending on local patient complexity and service delivery. This should include both direct patient contact time, team discussions and strategic involvement. This is supported and stated in national guidance as set out by the Intensive Care Society (GPICS V2).

Speech and language therapy services for people with critical care needs should be provided in a collaborative multidisciplinary context, to ensure the philosophy and goals of intervention are shared, consistent and most effective.

The role of the SLT includes:

  • The provision of specialist knowledge and skills in the clinical management of people with communication or swallowing difficulties. This includes the use of instrumental assessments to inform suitable interventions.
  • Raising awareness of the importance of communication and swallowing through education and training.
  • The assessment and management of communication and swallowing in all patients with a tracheostomy with or without ventilatory support.
  • Advocacy for patients who are unable to speak and empowering communication skills using alternative or augmentative methods.
  • Facilitation of communication to support decision-making including capacity assessments.
  • Working with other therapeutic services provided in critical care, to support the understanding of communication needs and limitations in a developmentally appropriate way. This may include
  • Occupational Therapists, Physiotherapists, Play Therapists, music therapists and education teams.

It is the responsibility of speech and language therapy services to contribute to strategic and service planning, clinical governance, quality improvement, audit and research as part of the role in critical care. 

Practice guidelines

The RCSLT recommends that all SLTs working in critical care follow the guidelines below and adhere to the RCSLT tracheostomy and FEES competency frameworks.

Awareness raising

  • Participate in clinical and strategic meetings to raise awareness of the value of speech and language therapy to the service and the contribution of optimal management of communication and swallowing difficulties for critical care patients. Please note that:
    • Clinical meetings include: ICU ward rounds, tracheostomy teams, MDT meetings, clinical governance and clinical audit.
    • Strategic meetings include: service development, Quality Improvement (QI), Morbidity and Mortality (M&M), strategic steering groups, regional network meetings.
  • Promote early access to  speech and language therapy regardless of ventilation needs or tracheostomy cuff status.

Assessment and management

  • Assess and manage swallowing and communication problems in any critical care patient.
  • It is strongly recommended that SLTs are present at initial trials of Above Cuff Vocalisation (ACV) (McGrath et al., 2015; 2018), cuff deflation and use of speaking/one way valves (Sutt et al., 2016), guided by instrumental evaluation.
  • Contribute to the MDT weaning plan for complex or long stay tracheostomy and ventilator dependent patients (Bonvento et al., 2017).
  • Carry out instrumental methods of assessment of post-extubation dysphagia (Brodsky et al., 2018; Perren et al., 2019; Scheel et al., 2015), secretion management, laryngeal integrity, dysphagia severity and silent aspiration risk. This can be either fibreoptic endoscopic evaluation of swallowing (FEES) which can be done at bedside or videofluoroscopy, (VFS) (see RCSLT’s dysphagia section) which will require transfer to a radiology environment.
  • The speech and language therapy role using FEES is essential for determining a therapy or rehabilitation plan and provides valuable clinical information for MDT tracheostomy weaning decisions.
  • Management could include the use of speaking/one way valves and ACV to promote laryngeal function for sensation, swallowing and/or restoration of voice.
  • Assess and advise on a range of alternative and augmentative communication (AAC) aids.
  • Use specialist skills to inform differential diagnosis regarding the nature and cause of communication and swallowing difficulties, including intubation trauma, cognitive-linguistic difficulties/cognitive difficulties and disorders of consciousness. 
  • Provide a supporting role in capacity assessments for those with communication or cognitive impairments.
  • Provide an appropriate rehabilitation programme at a level that enables the patient to meet their rehabilitation goals for as long as they are continuing to benefit from the therapy and are able to tolerate it (GPICS V2).
  • Support and facilitate a developmentally appropriate approach to communication and feeding for the paediatric caseload in the critical care environment.
  • Provide ongoing speech and language therapy involvement, delivering rehabilitation throughout the patient’s journey from critical care to ward transfer - both prior to and after discharge. This includes MDT discussion, goal planning and onward referral if appropriate. See NICE guidance for Rehabilitation after Critical Illness for Adults (QS158, 2017) and NHS England service specification for paediatric neurorehabilitation.
  • Clinical outcomes can be measured using a number of existing tools, such as:

For more information please see the RCSLT outcome measurement section.

Training and support

  • Provide training to the wider MDT and carers regarding communication and swallowing difficulties, and the impact of tracheostomy in order to support any intervention or rehabilitation programme.
  • SLTs with critical care experience have a responsibility to provide competency training and clinical support to other SLTs to develop their skills.

Service improvement and governance

Further resources on the role of speech and language therapy can be found in the National Guidance section.

See also RCSLT general guidance on Care Pathways, including Referrals, Assessment, Management and Discharge

Collaborative working

There are a range of healthcare professionals that work either exclusively or periodically in the critical care environment. SLTs should be familiar with their roles and how they can interlink with them. Attendance at ward/board rounds and team meetings helps to understand the clinical priorities for each patient. Other professionals include: (this list is not exhaustive)

  • dietitians
  • doctors
  • nurses
  • occupational therapists
  • palliative care teams
  • pharmacists
  • physiotherapists
  • play therapists
  • psychologists
  • radiologists

SLT’s often provide periodic input into critical care, therefore collaborative working is essential for optimising patient outcomes and influencing the MDT decision-making process. SLTs should understand the impact of the recommended interventions on all aspects of care and develop a joint plan for implementation.

SLTs should contribute to patient-centred goal setting and completion of rehabilitation plans or prescriptions, as recommended by NICE guidance (CG83 and QS158).

SLTs have professional autonomy and decisions about patient care that should be discussed, agreed and documented with the team around the adult or child. Integrated care pathways may be utilised for patient groups, and these should feature access to speech and language therapy if required.

The SLT also has a role in raising awareness of their skills and specialism so that they are involved with patients at the right time. Capturing data and measuring outcomes, is also important to demonstrate the impact that SLTs have clinically, and as part of team decision-making. It is important to be cognisant of the fact that the areas SLTs work on - communication and swallowing - will need to be monitored and overseen by others, therefore, SLTs and other professionals need to work together.

Refer to national guidance section for more information. Please also see the RCSLT guidance on collaborative working and GPICS V2.

Medico legal issues

Staff need to ensure they work within their scope of practice with adherence to local health and safety policies, as stated in their job description and are aware of their legal obligations to the employing organisation.

The SLTs right to practice is governed by the regulations of the Health and Care Professions Council and adherence to the code of practice is the professional responsibility of the individual therapist. The RCSLT is the professional body for SLTs and provides guidance and support to meet standards in addition to indemnity insurance. Members can contact the RCSLT for advice about any areas of practice development including legal support.

For patients in critical care, there may be ethical and end of life decisions being made that may have an impact on speech and language therapy recommendations. It is important to maintain communication with the team to ensure that patient preferences and needs for best care are met. Most trusts will have a clinical ethics committee to support challenging decision-making.

SLTs must be involved in the discussions around risk feeding with local policy to support decision-making and treatment escalation plans. A national report by the Royal College of Physicians sets out guidance for teams when oral feeding becomes a dilemma (RCP, 2010).

National guidance

On the right Trach: A review of the care received by patients who underwent a tracheostomy, NCEPOD (2014)

Guidelines for provision of intensive care services (GPICS) Intensive Care Society (2018)

Core Standards for Intensive Care Units Intensive Care Society  (2015)

UK National Tracheostomy Safety Project National Tracheostomy Safety Project (2013)

National Critical Care Non-Medical Workforce Survey Report Clinical Reference Group for Adult Critical Care & the Clinical Leadership Forum (2016)

Rehabilitation after critical illness, NICE clinical guideline 83 (2009)

Trauma, NICE Quality Standard 166 (2018)

Rehabilitation after critical illness in adults, NICE Quality Standard 158 (2017)

Weaning guidelines for spinal cord injured patients in critical care units, RISCI (2012)

Guidance on clinically-assisted nutrition and hydration for adults who lack capacity, BMA (2018)

Oral feeding difficulties and dilemmas A guide to practical care, particularly towards the end of life. RCP (2018)

Prolonged disorders of consciousness, RCP national clinical guidelines (2013)

Extracorporeal Life Support and ECMO guidelines for respiratory support  Extracorporeal Life Support Organization (ELSO) (2017)

Service Specification for Paediatric neurorehabilitation NHS England, (2013/14)

Neonatal specialist care Quality Standard NICE, (2010)

Caring for the child/young person with tracheostomy Best Practice Statement, NHS Quality Improvement Scotland (2008)

Clinical Practice Guideline for the Management of Communication and Swallowing Disorders Following Paediatric Traumatic Brain Injury Morgan, A., Mei, C., et al. (2017), Melbourne (Australia):

Murdoch Childrens Research Institute, 1-45.

AHP Critical Care Professional Development Framework Intensive Care Society, (2018)

Advanced Clinical Practice roles NHS England (2019)

For more resources see RCSLT critical care Learning pages. 

National policy

Here you will find links to relevant national legislation, policy and frameworks. 

Please note that this list is not exhaustive. Please contact us if you have any suggestions.

England

NHS Long Term Plan NHS England (2018)

NHS England Commissioned Critical Care Services NHS England (accessed 2019)

NHS England Paediatric Critical Care and Specialised Surgery Review NHS England (accessed 2019)

Intensive Care National Audit and Research Centre Intensive Care and National Audit & Research Centre (2018/19)

Wales

Welsh Government Delivery Plan for the Critically Ill to 2020 Wales Critical Care and Trauma Network and the Critically ill Implementation Group (2017)

Welsh Intensive Care Society Welsh Intensive Care Society (accessed 2019)

Designed for Life: Quality Requirements for Adult Critical care in Wales All Wales Critical Care Development Group (2006)

Implementing Quality Requirements for Adult Critical Care Services Second Strategic Framework (2008-2011)

NHS Wales 1000 Lives Campaign Public Health Wales (2019)

Caring for Critically Ill children NHS Wales (2003)

Scotland

Scottish Intensive Care Society Scottish Intensive Care Society, (accessed 2019)

Scottish Intensive Care Society Audit Group (SICSAG) Scottish Intensive Care Society Audit Group (accessed 2019)

Minimum Standards and Quality Indicators for Critical Care in Scotland Scottish Intensive Care Society Quality Improvement Group, (2015)

Northern Ireland

Health and Wellbeing 2026: Delivering together NI Dept. of Health (2016)

A Strategy for Children’s Palliative and End-of-Life Care 2016-26 NI Dept. of Health (2016)

References

American Speech-Language-Hearing Association. National Outcomes Measurement System (NOMS).

Bonvento, B., Wallace, S., Lynch, J., Coe, B., & McGrath, B. A. (2017). Role of the MDT in the care of the tracheostomy patients. Journal of Multidisciplinary Healthcare, 11(10), 391-398. doi:10.2147/JMDH.S118419.

Bray, K. (2005). Mental Capacity Act 2005 England and Wales: a short summary. Nurs Crit Care, 10(6), 300-301.

Brodsky, M. B., Levy, M. J., Jedlanek, E., Pandian, V., Blackford, B., Price, C., . . . Akst, L. M. (2018). Laryngeal Injury and Upper Airway Symptoms After Oral Endotracheal Intubation With Mechanical Ventilation During Critical Care: A Systematic Review. Crit Care Med, 46(12), 2010-2017. doi:10.1097/ccm.0000000000003368.

Crary, M. A., Mann, G. D., & Groher, M. E. (2005). Initial psychometric assessment of a functional oral intake scale for dysphagia in stroke patients. Arch Phys Med Rehabil, 86(8), 1516-1520. doi:10.1016/j.apmr.2004.11.049.

Department of Health. (2000). Comprehensive Critical Care. Retrieved from http://webarchive.nationalarchives.gov.uk/20130107105354/http:/www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4082872.pdf

Enderby, P., & John, A. (2015). Therapy Outcome Measures for Rehabilitation Professionals (3rd edition edition (1 Jan. 2015) ed.): J & R Press Ltd.

Faculty of Intensive Care Medicine (FICM), & The Intensive Care Society (ICS). (2018). Guidelines for the Provision of Intensive Care Services (GPICS) Version 2. Retrieved from https://ficm.ac.uk/sites/default/files/gpics-v2-final2019.pdf

Grover, S., & Kate, N. (2012). Assessment scales for delirium: A review. World journal of psychiatry, 2(4), 58-70. doi:10.5498/wjp.v2.i4.58

McGrath, B., Lynch, J., Wilson, M., Nicholson, L., & Wallace, S. (2015). Above cuff vocalisation: A novel technique for communication in the ventilator-dependent tracheostomy patient J Intensive Care Soc, Vol 17(1), 19 - 26.

McGrath, B. A., Wallace, S., Wilson, M., Nicholson, L., Felton, T., Bowyer, C., & Bentley, A. M. (2018). Safety and feasibility of above cuff vocalisation for ventilator-dependant patients with tracheostomies. Journal of the Intensive Care Society, 0(0), 1751143718767055. doi:10.1177/1751143718767055.

Murray, J., Langmore, S. E., Ginsberg, S., & Dostie, A. (1996). The significance of accumulated oropharyngeal secretions and swallowing frequency in predicting aspiration. Dysphagia, 11(2), 99-103. doi:10.1007/bf00417898.

National Institute for Clinical Excellence. (2017). Rehabilitation after Critical Illness in Adults Quality Standard [QS158].

The National Institute for Health and Clinical Excellence. (2009). NICE clinical guideline 83: Rehabilitation after critical illness.

Neubauer, P. D., Hersey, D. P., & Leder, S. B. (2016). Pharyngeal Residue Severity Rating Scales Based on Fiberoptic Endoscopic Evaluation of Swallowing: A Systematic Review. Dysphagia, 31(3), 352-359. doi:10.1007/s00455-015-9682-6.

Paediatric Intensive Care Society. (2015). Quality Standards for the Care of Critically Ill Children Retrieved from http://picsociety.uk/wp-content/uploads/2016/05/PICS_standards_2015.pdf.

Perren, A., Zürcher, P., & Schefold, J. C. (2019). Clinical Approaches to Assess Post-extubation Dysphagia (PED) in the Critically Ill. Dysphagia. doi:10.1007/s00455-019-09977-w.

Rosenbek, J. C., Robbins, J. A., Roecker, E. B., Coyle, J. L., & Wood, J. L. (1996). A penetration-aspiration scale. Dysphagia, 11(2), 93-98.

Scheel, R., Pisegna, J. M., McNally, E., Noordzij, J. P., & Langmore, S. E. (2015). Endoscopic Assessment of Swallowing After Prolonged Intubation in the ICU Setting. Ann Otol Rhinol Laryngol, 125(1), 43-52. doi:10.1177/0003489415596755.

Sutt, A. L., Caruana, L. R., Dunster, K. R., Cornwell, P. L., Anstey, C. M., & Fraser, J. F. (2016). Speaking valves in tracheostomised ICU patients weaning off mechanical ventilation--do they facilitate lung recruitment? Crit Care, 20, 91. doi:10.1186/s13054-016-1249-x

Turner-Stokes, L. (2009). Goal attainment scaling (GAS) in rehabilitation: a practical guide. Clin Rehabil, 23(4), 362-370. doi:10.1177/0269215508101742

Ward EC and Conroy AL. Validity, reliability and responsivity of the Royal Brisbane Hospital Outcome Measure for Swallowing. Asia Pacific Journal of Speech, Language and Hearing 1999; 4: 109-129. DOI: 10.1179/136132899805577051.

Zigmond, A. S., & Snaith, R. P. (1983). The hospital anxiety and depression scale. Acta Psychiatr Scand, 67(6), 361-370.