Dysphagia Management in the Emergency Department: Using Concept Mapping to Identify Actionable Change to Improve Services.

BACKGROUND: Integrated speech-language pathology (SLP) services within the emergency department (ED) may facilitate timely dysphagia management. However, there are multiple patient and logistical factors specific to the ED that challenge the delivery of optimal dysphagia referral and management practices within this setting. The aim of the current study was to engage a stakeholder group to identify prioritised, actionable goals that could help enhance dysphagia management within the ED. METHODS AND PROCEDURES: Applying concept mapping methodology, 16 ED stakeholders from SLP, medical, nursing, and leadership participated in semi-structured interviews to develop action statements which were sorted and ranked for importance and changeability. Multidimensional scaling and hierarchical cluster analysis were used to organise data in clusters with unifying themes before statements were ranked by importance and changeability. OUTCOMES AND RESULTS: Stakeholders identified 53 unique statements, grouped into 8 clusters. Review of the 8 clusters identified 3 overarching aspects for change: (a) Improving processes related to identification and referral of patients as well as communication; (b) Teamwork and collaboration amongst the ED multidisciplinary team and SLP; and (c) Improving staffing and access to training resources for SLP and nursing teams. Seventeen statements were within the Go-zone rated highest for importance and changeability) with the highest rated statement being: Clear documentation by SLP re: recommendations. CONCLUSION: The current data identified multiple aspects of service provision that require change to facilitate improved dysphagia referral and management services in the ED. Collaborative actions are required by both SLP and the ED multidisciplinary team to help optimise dysphagia services.

Nature and timeliness of dysphagia management within an emergency setting.

PURPOSE: To examine referral pathways, clinical demographics, and timeliness of dysphagia management within an emergency department (ED) setting utilising both ED staff and speech-language pathology (SLP) initiated referral pathways. METHOD: Six-month retrospective service review of patients who received dysphagia assessment by SLP within a major Australian ED. Data were collected on demographics, referral information, and SLP assessment and service outcomes. RESULT: Three hundred and ninety-three patients were assessed by SLP staff in the ED, consisting of 200 stroke and 193 non-stroke referrals. In the stroke cohort, 57.5% of referrals were initiated by ED staff, while 42.5% were SLP initiated. ED staff initiated 91% of non-stroke referrals, with few (9%) proactively identified by SLP staff. SLP staff identified a higher proportion of non-stroke patients within 4 hr of presentation compared to ED staff. Stroke patients identified by SLP staff were more likely to have assessments completed within 8 hr compared to the ED referral pathway. Collectively, 51% of patients required ongoing dysphagia management following initial assessment. CONCLUSION: Findings provide an overview of SLP services and referral pathways in an ED context. The SLP initiated referral pathway facilitated early assessment of stroke patients, and collaboration with ED staff was integral in referring other at risk populations. SLP/ED synergy is needed for appropriate and timely dysphagia management practices in an ED.

Outcomes of a first point of contact speech language therapy clinic for patients requiring vocal cord check pre and post thyroid/parathyroid surgery.

INTRODUCTION: Speech Language Therapy First Point of Contact Clinic (SLT-FPOCC) models can assist assessment of low-risk patient populations referred to ear, nose and throat (ENT) services. To further improve ENT waitlist management and compliance with best-practice care, consideration of other low-risk populations that could be safely managed through this service model is needed. The aims of this paper are to evaluate the clinical and service outcomes of completing vocal cord check (VCC) assessments for patients' pre and post thyroid/parathyroid surgery within an SLT-FPOCC model and examine consumer perceptions. METHODS & PROCEDURES: The service followed existing SLT-FPOCC procedures, with ENT triaging referrals, then SLT completing pre- and postoperative VCC assessment (interview, perceptual assessment, flexible nasendoscopy), with assessment data later reviewed by ENT to diagnose laryngeal pathology. Clinical and service outcomes were collected prospectively. Patients completed an anonymous post-service satisfaction survey. RESULTS: Of the first 100 patients referred for preoperative VCCs, SLT assessment identified 42 with dysphonia and 30 reporting dysphagia, while ENT confirmed 9 with significant preoperative anatomical findings. Eighty-three underwent surgery, with 63 (95 nerves at surgical risk) returning for a postoperative VCC. Postoperative VCC identified three temporary neuropraxias (3.2%) and three unilateral vocal fold paresis (3.2%). Patients were highly satisfied with the service. All 163 pre-/postoperative VCCs were completed with no adverse events. CONCLUSION & IMPLICATIONS: The current data support SLT-FPOCC service expansion to include pre and post thyroid/parathyroid surgery VCC checks, with positive consumer perception. The model supports delivery of best practice management (i.e., pre- and postoperative VCC) for patients receiving surgery for thyroid/parathyroid dysfunction, and associated efficiencies for ENT services. WHAT THIS PAPER ADDS: What is already known Assessment of laryngeal function via flexible nasoendoscopy is recommended best practice for patients pre and postthyroid/parathyroid surgery, as recurrent laryngeal nerve injury is a low incidence (<10%), yet well-recognised risk of these surgeries. Traditionally, general surgeons refer presurgical patients to ear, nose and throat (ENT) for vocal cord check (VCC) assessment. However, with access to specialist outpatient services under increasing pressure, there is growing support for utilisation of other health professionals, such as speech-language therapists working in first point of contact (FPOCC) models, to assist with the administration of pre- and postsurgical assessments of such low-risk populations. What this study adds This work expands on the emerging body of evidence for speech language therapy (SLT) led FPOCC models within ENT outpatient services, providing clinical and service outcomes to support the safety of a new model designed to administer VCCs for patients pre and post thyroid/parathyroid surgery. Adopting a similar model to a prior published SLT-led FPOCC model, the trained SLT completes the pre- and postsurgical VCC including flexible nasoendoscopy and videostroboscopy, with images and clinical information then presented to ENT for diagnosis and management planning. This study also provides the first data on consumer perceptions of this type of service model. Clinical implications of this study Data on 100 consecutive presurgical patients revealed positive service findings, supporting the safety of this model. Nature and incidence of clinical findings pre and post surgery were consistent with previously published studies using traditional models of care (i.e., ENT completing the flexible nasendoscopy). Consumer perception was positive. This model enables delivery of pre-and postsurgical assessments for patients receiving thyroid/parathyroid surgery, consistent with best practice care, and reduces burden on ENT services. In total 163 ENT appointments were avoided with this model, with positive implications for ENT waitlist management.

Understanding barriers and facilitators to speech-language pathology service delivery in the emergency department.

PURPOSE: Timely speech-language pathology (SLP) involvement with dysphagic patients in the Emergency Department (ED) may improve patient outcomes. This study utilised qualitative interviews to understand current models and explore factors which have influenced establishment and current dysphagia service provision in Australian EDs. METHOD: Semi-structured interviews were conducted with representatives from 12 acute hospital facilities with a SLP ED service. Interview transcripts were analysed using plain content analysis to identify key themes. Sub-analysis using the Consolidated Framework for Implementation Research (CFIR) model was undertaken for facilities with more "expanded" models (n = 4). RESULT: SLP ED service models ranged from referral-only services, to models with referral-only and proactive SLP-led screening procedures (classified as "expanded"). Patient-related factors, the ED setting, SLP service factors and perceptions of dysphagia management were key themes reported to impact service delivery. With expanded models, 14 CFIR constructs (innovation source, external policy and incentives, networks and communications, stakeholders and relative priority) were identified as facilitators, while four constructs (adaptability, cost, compatibility, available resources) were barriers to services. CONCLUSION: There are service-specific issues with providing SLP care within the ED. Factors related to the unique ED environment must be considered by SLP departments when establishing/optimising dysphagia management within the ED.

Evaluation of health service outcomes for an audiology first point of contact retrocochlear clinic: a 6-year retrospective cohort study.

OBJECTIVE: Although existing studies of audiology first point of contact clinics which screen for retrocochlear pathology have demonstrated positive clinical outcomes, they have provided limited information regarding service impacts. Thus, this study aimed to evaluate both the clinical and health service outcomes of an audiology first point of contact (FPOC) clinic for adults referred to ENT services with suspected retrocochlear pathology. DESIGN: Retrospective cohort study. STUDY SAMPLE: All 1123 patients referred to the clinic over a 6-year period (2013-2019). RESULTS: Most (73.7%) of the 1123 patients referred to the Retrocochlear Clinic were managed and discharged by the audiologist and did not require ENT appointment. Almost half (43.1%) were directly referred for MRI imaging, of which 4 (1.1%) were diagnosed with Vestibular Schwannoma. Waiting times for first appointments significantly (p < 0.001) reduced from a median of 748 days to 63.5 days over the 6-year period. Attendance rates also significantly (p < 0.001) improved over this time (from 52.2% to 90%). There were no adverse events reported. Of those discharged without attending an ENT appointment, 1.8% were rereferred to ENT within 12 months of discharge. CONCLUSIONS: This audiology FPOC Retrocochlear Clinic was shown to be a safe and effective alternative service model.

Speech pathology prescribing in the outpatient setting: A review of requirements, considerations and barriers.

BACKGROUND: As health systems face increasing demands, non-medical prescribing is a workforce redesign strategy adopted within some services. Despite successful implementation in other professional groups, non-medical prescribing within speech pathology (SP) has not yet been described. AIMS: To provide a descriptive account of the development and planned implementation of two SP prescribing models. METHODS & PROCEDURES: The evolution of two SP-led prescribing models, including relevant training and credentialing, for use of (1) nystatin oral drops (100,000 units/mL); and (2) lidocaine (lignocaine) and phenylephrine nasal spray (5 mg/500 µg/spray), in the outpatient setting is detailed. Challenges to implementation are outlined. MAIN CONTRIBUTION: The development of relevant governance structures, a research evidenced-based project evaluation framework, and an overview of training pathways and credentialing was successfully completed. However, implementation of the models was unable to be achieved. A thorough review of the requirements and a discussion of contextual considerations that had a negative influence on the implementation of SP-led prescribing within this specific service context is provided. CONCLUSIONS & IMPLICATIONS: The successful implementation of SP-led prescribing is complex and highly context dependent. This work offers a discussion and review of the complexities of introducing a non-medical prescribing model in an outpatient hospital setting. WHAT THIS PAPER ADDS: What is already known on the subject Allied Health prescribing is an emerging practice area aiming to reduce current pressures on health services. SP-led prescribing has not been thoroughly investigated in the Australian context. What this study adds to existing knowledge This study describes the development of a SP-led prescribing process in the outpatient setting, and a thorough review and discussion of the drivers and barriers to the model's implementation. What are the potential or actual clinical implications of this work? The successful implementation of SP-led prescribing was identified to be complex from a legislative and operational perspective, as well as being highly context dependent. This study further highlights the importance of a thorough context evaluation and workflow mapping prior to full-scale implementation of SP prescribing trials.

Digital dashboards: a speech pathology case study.

The introduction of electronic medical records has created vast opportunities in relation to data storage, visibility and extraction. In Allied Health the collection, storage, display and reporting of service statistics is a key opportunity to utilise the capabilities of the electronic medical record to reduce clinician time completing data entry, improve accuracy and visibility of available data and maximise opportunities to view and utilise service statistic information in clinical and operational decision making. This case study describes service statistic capture and extraction for a speech pathology department, pre- and post- the introduction of a digital dashboard. A new Allied Health digital dashboard was created via clinicians and informaticians working collaboratively to define service delivery elements for data extraction and design dashboard functionality. Descriptive comparison of data capture pre- and post- dashboard implementation was undertaken. The integration of service statistic information into a digital dashboard was found to support service statistic reporting, improve ease of access, and provide greater visibility and timeliness of service information.

Outcomes from an extended scope of practice speech-language pathology service for low risk ENT outpatients: A 5-year service review.

Purpose: Early evidence supports the safety and efficiency of extended scope speech-language pathology (SLP) clinics designed to manage low risk ear nose and throat (ENT) outpatient referrals, however long-term data is lacking. The aim of this study was to complete a 5-year audit of clinical outcomes, including rates of re-referral, for a SLP Allied Health Practitioner (SLP AHP) led dysphagia and dysphonia service within an Integrated Specialist ENT Service.Method: A retrospective audit was undertaken of all patients referred with non-urgent dysphonia and/or dysphagia symptoms over a 5-year period since establishment of the SLP AHP service. Clinical outcomes, rates and reasons for re-referral to the specialist ENT waiting list were investigated.Result: Of 616 patient referrals, 462 patients were seen by the SLP AHP service. Most (72%, n = 333) received all required management through the clinical model, with only 28% (n = 129) requiring additional ENT intervention, consistent with previously published data. Only 36 of the 616 (6%) were re-referred/re-presented within 12 months of first presentation, of which only 12 were referred for same condition as initial referral. No adverse outcomes were recorded on the clinical database during this 5-year period.Conclusion: Results provide further evidence that the SLP AHP service is a safe and efficient method for managing low risk ENT outpatient referrals.

Implementation of an extended scope of practice speech-language pathology allied health practitioner service: An evaluation of service impacts and outcomes.

PURPOSE: Extended scope of practice roles can address health service challenges and enhance patient services; however there has been limited research of extended scope roles in the discipline of speech-language pathology (SLP). The aim of this study was to examine the clinical outcomes and service impacts of a Speech-Language Pathology Allied Health Practitioner (SLP AHP) led dysphagia and dysphonia service within an Integrated Specialist Ear Nose and Throat (ENT) Service. METHOD: Low risk referrals were triaged by ENT from the waiting list into the SLP AHP dysphagia and dysphonia clinic. Outcomes from an initial 6-month pilot phase (n = 43) and 6-month implementation phase (n = 158) were evaluated. RESULT: Approximately 70% of patients managed in the SLP AHP clinic in both phases were discharged without requiring separate ENT appointments. There were no adverse events. In the pilot phase, only 4.3% of medium priority and 10% of low priority referrals were seen within clinically recommended time frames. This improved to 90% in the final three months of the implementation phase. CONCLUSION: With appropriate governance and risk management, an extended scope SLP AHP service for low risk dysphagia and dysphonia can achieve safe, effective and beneficial changes to ENT service delivery.