Swallowing and communication assessment in tracheostomy patients: Multi-disciplinary-led quality improvement in a busy tertiary teaching hospital

ABSTRACT

Introduction: Intensive care patients often have complex swallowing and communication needs. These require coordinated input from the multi-disciplinary team. Increasing evidence highlights the role of speech and language therapy (SLT) within the critical care environment1 and this is represented well in national recommendations specific to patients with tracheostomies. Approximately 10-15% of ICU patients will have a tracheostomy nationally.2 SLT provide expertise in assessment and management of communication and swallowing difficulties, which can vastly improve psychosocial well-being and promote early safe enteral feeding for our patients.3 In 2014 On the right trache?4 found that 52% of patients with a tracheostomy suffered with dysphagia, however only 27% critical care patients had input from SLT. Objectives: To improve the assessment of swallowing and communication in patients undergoing tracheostomy ventilation at the Royal Infirmary of Edinburgh, to comply with Scottish Intensive Care Society Audit Group (SICSAG) quality indicator 2.3. This guidance stipulates all tracheostomy patients should have communication and swallowing needs assessed during ventilator wean.5 Methods: Four distinct areas of intervention were implemented. Pre-populated review text was added to NHS Lothian's clinical notation system (InterSystems TrakCare®), prompting nursing staff to consider swallowing, tracheostomy issues and SLT referral. These were refined between audit cycles. SLT were invited to join safety briefs to identify tracheostomy patients, as well as other patients with complex swallowing needs. This was an opportunity to raise awareness, educate, and prioritise workload. New guidelines for nurse-led swallowing observations were developed and disseminated amongst teams. Finally, staff were offered relevant educational sessions. Baseline data was collected in 2019;serial data collection was then during October - November 2020 and in June - July 2021 following the interventions. Results: All patients who received tracheostomy ventilation were audited (n=31). This showed that very few patients had swallowing and communication assessed adequately. Only 16.1% (n=5) patients had a regular nursing swallowing assessment on the majority of critical care days (>50%). Referral to SLT was often very late when patients were approaching de-cannulation and on many occasions by the time the SLT team were involved patients had already been de-cannulated. Following the intervention period, it became apparent that awareness of swallowing requirements had improved. By mid 2021, 58.9% more patients had swallowing assessed as part of daily care. Additionally, 81.2% of patients had SLT reviews on the unit demonstrating a sustained increase from late 2020. There was a notable increase in the quality of assessments after initial SLT review. Conclusion: Using quality improvement methodology our multidisciplinary team was able to substantially increase the quality of swallowing assessment within our ICU, despite the challenges of the COVID-19 pandemic. Our unit now complies with SICSAG quality indicator 2.3. This is in keeping with national recommendations for a multidisciplinary approach to care of tracheostomy patients. Patients with increased risk of dysphagia are being identified earlier and are more likely to progress and be established on enteral feeding early, which may subsequently reduce the burden of nasogastric feeding, total parenteral nutrition and even related invasive IV access.