Critical care overview
- People with a range of illnesses, diseases and accidents are admitted to critical care units for urgent medical and nursing care. They may experience either temporary or long term difficulties with swallowing and communication.
- These needs are very important for patients and their recovery, so speech and language therapists (SLTs) can help to evaluate difficulties.
- Early speech and language therapy input can improve patient care and outcomes; helping to reduce the length of time spent in critical care or hospital, which helps to save hospital resources.
- SLTs provide specialist knowledge and skills about the functions of the throat for speaking and swallowing, so they understand what is the best type of therapy for improvement.
- SLTs are key members of the multidisciplinary team and support critically ill patients in their therapy and clinical management of communication, voice, swallowing, ventilator and tracheostomy weaning.
What is critical care?
Critical care is the provision of specialised, continuous, and multidisciplinary care for patients in a life-threatening, but treatable, condition. Levels of care help to determine the appropriate staffing ratio – in the UK, Level 3 means one trained dedicated critical care nurse per patient, plus access to multidisciplinary therapy staff when required (GPICS, 2019).
Critical care encompasses the range of intensive care units including:
- cardiothoracic intensive care units (CTICU),
- general intensive care units (GICU),
- neurological intensive care units (NICU),
- paediatric intensive care units (PICU), and;
- high dependency units (HDU)
Critical illness can be a very distressing experience for patients and relatives. Recovery can take a long time, and patients can be left with physical and psychological after effects.
Those in critical care may require some or all of the following:
- 24 hour 1:1 nursing care, with input from specialist healthcare professionals.
- Continuous, uninterrupted physiological monitoring, supervised by staff who are able to interpret and immediately act on the information.
- Continuous clinical direction and care from a specialist consultant-led medical team, who are trained and able to provide appropriate cover appropriate for each critical care unit.
- Advanced therapies which are only safe to administer in the above environment.
People in critical care will also be treated by a range of critical care specialists, including; doctors, physiotherapists, pharmacists, technicians, SLTs, occupational therapists, psychologists and dietitians.
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How can speech and language therapy help in critical care?
SLTs have a vital role in optimising the care, experience, safety and outcome of patients whilst they are on critical care through to their ongoing rehabilitation.
The role of SLTs would include:
- The specialist assessment and treatment of any communication problems which may happen as a result of a condition or the treatment to help that condition, such as needing a tracheostomy (McGrath et al., 2018; Sutt et al., 2016; Freeman-Sanderson A, et al., 2016; Costello et al., 2010; Mobasheri et al., 2016).
- The specialist and detailed assessment and management of swallowing problems that would include: too much or too little saliva, difficulty drinking fluids, eating textured foods and taking medications. This information is shared with the wider team to help with decisions that are made for nutrition and medication management (Sproson, Pownall, Enderby, & Freeman, 2017; Restivo and Hamdy, 2018; Marcus et al., 2019; UK National Tracheostomy Safety Project, 2013).
- Working as part of a team to problem-solve complex communication or swallowing difficulties, especially for those with tracheostomy and/or ventilation (Bonvento et al., 2017; Frank et al., 2007; Hafner, Neuhuber, Hirtenfelder, Schmedler, & Eckel, 2008; Heidler, Bidu, Friedrich, & Voller, 2015; Rose, 2011).
- Using a range of assessments, including instrumental assessments, such as Fibreoptic Endoscopic Evaluation of Swallowing (FEES) and videofluoroscopy (VFS), which SLTs are trained to use to support the clinical decisions for weaning someone off their ventilator or tracheostomy tube, identifying the best therapy for swallowing problems and voice production (Bonvento, Wallace, Lynch, Coe, & McGrath, 2017; Sutt et al., 2016; Frank, Maeder, & Sticher, 2007; Hales, Drinnan, & Wilson, 2008; McGowan, Gleeson, Smith, Hirsch, & Shuldham, 2007).
- Providing training to nursing, medical and therapy staff on the best way to support SLT input to benefit a patient’s rehabilitation, this may include involvement in mental capacity decisions or those experiencing delirium (Jayes, Palmer, & Enderby, 2017;Traube et al., 2017).
- Teaching the patient techniques, strategies and methods to improve their swallowing and speech, which helps their road to recovery (Logemann, 1998).
- Setting goals for rehabilitation and monitoring change on a regular basis to re-evaluate and reset goals.
- Using outcome measures to evaluate the effectiveness of therapy.
In the critical care setting speech and language therapy services need to be provided in a collaborative multidisciplinary context, with regular team discussion to ensure the best outcome for people with these difficulties. Regular contribution to audit and service evaluation are important to ensure compliance with governance requirements.
What can you expect from speech and language therapy in critical care?
SLTs should be contacted by the critical care team detailing the problems that require their input. The SLT will gather information about the patient’s condition and treatment they are currently receiving and liaise with other staff members and family members to understand the nature of the problem relating to speaking, swallowing and tracheostomy management.
Following this, the SLT will assess the patient to identify the specific difficulties, which will include an assessment at the bedside and discussion with the nurse caring for the patient. A recommendation for treatment will be given, which would include direct speech and language therapy, indirect guidance to the team and family, and a plan for ongoing review and expected outcomes.
A decision to use instrumental assessments will be discussed and agreed with the team, the patient, and any family members to ensure informed consent or best interest decisions, if there are issues around mental capacity. Following this assessment, results will be documented and shared with the team with options for further therapy input.
Speech and Language Therapy
Depending on the problems identified, SLTs will make recommendations such as:
- The additional mouth care needs for patients with dysphagia to help manage the symptoms of dry mouth and thirst.
- Practising swallowing movements, voice and breathing exercises to help get the throat working better.
- Using specific swallow therapy strategies to improve the effectiveness and safety of the swallow.
- Avoiding eating and drinking certain foodstuff until the ability to swallow improves.
- Recommending the drinking of modified fluids to overcome a specific swallowing problems.
- Recommending a modified diet to overcome specific swallowing problems.
The SLT will provide therapy input on a regular basis, and this may vary with the additional support and input from nurses, therapists and family members. Progress will be evaluated and recommendations will vary so that therapy input is responsive and up to date. Once these difficulties start to resolve, speech and language therapy input will reduce and may no longer be required. If problems persist after transfer from critical care, speech and language therapy input will continue to be provided by the speech and language therapy service.
- Edna’s story: The impact of speech and language therapy
- Benefits of Fibreoptic endoscopic evaluation of swallowing (FEES) (National Tracheostomy Safety Project)
- Tammy speaking for the first time (National tracheostomy safety project)
- Communication and swallowing in the hospital (NHS Bradford District Care Trust)
- Critical Care Professional Development Framework (2018) (Allied Health Professionals, 2018)
- On the right Trach (NCEPOD Tracheostomy Care, 2014)
- Guidelines for the Provision of Intensive Care Services (GPICS) Edition 2 (The Faculty of Intensive Care Medicine, 2019)
For related topics on the RCSLT website please see:
- RCSLT Clinical Information
- Acquired Motor Speech Disorders
- Augmentative and alternative communication (AAC)
- Brain injury
- Head and neck cancer
- Mental capacity and supported decision making
- Neonatal care
- Progressive neurological disorders
- Respiratory care adults
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Costello, J. M., Patak, L., & Pritchard, J. (2010). Communication vulnerable patients in the pediatric ICU: Enhancing care through augmentative and alternative communication. Journal of Pediatric Rehabilitation Medicine, 3(4), 289-301. doi:10.3233/prm-2010-0140
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Logemann, J. (1998). Evaluation and Treatment of Swallowing Disorders (2nd ed.). Austin, TX: Pro-Ed.
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UK National Tracheostomy Safety Project. (2013). National Tracheostomy Safety Manual. Retrieved from www.tracheostomy.org.uk