Speech and Language Therapy EPA2 Assesses and manages swallowing disorders in critical care

This EPA includes:

  • Determines suitability for swallowing assessment, considering clinical presentation, personal factors and wider treatment plan.
  • Uses appropriate swallow assessment tools.
  • Diagnoses dysphagia and develops an appropriate management plan.


  • Adult patients in critical care cleared for oral intake by the critical care and/or surgical team.


  • This EPA does not include patients with a tracheostomy, refer to Speech and Language Therapy EPA 3 and 4 for tracheostomy specific skills.
  • This EPA does not address FEES (endoscopy) and videofluoroscopy skills and competencies.

Print this EPA

You can print this EPA in a completable template by clicking print below.

If you select any prior completed EPAs via the options below the printable form will automatically mark these as "achieved".

EPA overview information
Required knowledge and skills
  1. C3Framework Shared AHP Competencies
  2. Speech and Language Therapy EPA 1: Assesses and manages communication disorders in critical care
  3. C3Framework Speech and Language Therapy Domains:
    • Critical Illness Equipment and Pathophysiology
    • Tools for Assessment: Swallowing
    • Critical Thinking and Clinical Reasoning: Swallowing
    • Working With Others: Swallowing
Assessment to measure progress
  • Review of anonymised patient records of complex patients and reflection pertaining to the Speech and Language Therapy management of the patient
  • Supervision documentation
  • Reflective reports
Basis for formal entrustment decisions

An entrustment decision should be made by an experienced critical care SLT after observing this EPA completed on more than one patient.

Use the EPA Completion Template (PDF, 88KB) for this.

Previously completed EPAs:
If you have completed any previous EPAs, select them here
to highlight where competencies have already been met.

Shared AHP competencies

Competency description Self assessment Senior assessment


Infection Prevention and Control:

Able to demonstrate knowledge of general infection control prevention and control including hand hygiene, aprons, masks and aseptic non-touch technique


Patient Emergency Management:

Has completed Basic Life Support Training as per local trust policy


Describes how they would summon help in an emergency and locate crash bells


Describes how to call a medical emergency call via switch


Describes own role and expected contribution in medical emergency eg. Basic Life Support, providing assistance to MDT as able


Patient ID:

Demonstrates positive patient identification and awareness of allergies


Monitoring Vital Signs:

Demonstrates how to monitor vital signs (Temp, HR, SpO2, RR, blood pressure, MAP)


Interprets observations in an ICU setting, considering trends and normal ranges for all (Temp, HR, SpO2, RR, blood pressure)


Able to troubleshoot difficulties with taking vital signs eg. poor trace on pulse oximeter, missing ECG leads, positional sensitivity of arterial line


Awareness of who to escalate concerns to in relation to patient safety with recognition of different levels of urgency and reporting to different staff members dependent on situation



Can describe the bed numbering, storage location of safety equipment, location of offices and other key areas within the critical care unit


Can describe the shift patterns and handover process of other MDT members


Able to identify key MDT members by their role, including critical care nurses, nurse in charge, consultant on call


Demonstrates how to locate the local protocols and guidelines relevant to own role


Has an awareness of key ICU meetings relevant to role e.g. MDT meetings, handovers, safety briefings, teaching sessions.


Can identify standard ICU bedspace equipment and location of equipment necessary for role



Communication with patient:

Describe barriers to communication in ICU including those associated with PPE, illness and ICU interventions.


Awareness of communication aids with patients to overcome communication barriers i.e. PPE + oral intubation


Communication with family + friends:

Describe the support services available to help liaise with family including family support nurses, PALS, psychology services as appropriate.


Describe barriers to communication with family and methods to improve this


Knows importance of confidentiality and consent to share information with friends and family


Communication with colleagues:

Awareness of peer support and psychological support



Local IT Training:

Demonstrates how to access and document in patient records using local IT systems


Demonstrates how to view results and imaging on local IT systems


Moving and Handling

Awareness of Falls prevention and who to escalate to if concerned regarding falls risks


Compliant with Manual Handling training as per local trust policy.


Non-technical skills


Demonstrate working in an MDT by building and maintaining relationships with other professions


Aware of the roles and responsibilities of other members of the MDT


Clarifies, accepts and executes tasks delegated by the team leader


Explains the importance of highlighting safety issues / concerns to a member of your team in a prompt manner


Uses appropriate level of assertiveness for the clinical situation


Demonstrates a logical and systematic handover using local format


Outline how to escalate and to whom if there are patient / safety concerns


Identify and respond to patient / staff safety issues appropriately


Clinical Assessment and Basic Life Support


Demonstrate ways to open up airway using simple manoeuvres (inc. repositioning, head tilt chin lift, jaw thrust)


Demonstrates how to deliver manual ventilation using two person bag-valve-mask (BVM) technique


Recognise and escalate airway compromise in a tracheostomised patient


Mouth care:

Demonstrates how to perform and document oral hygiene



Knows the types of oxygen delivery system and their limitations (including reservoir mask, simple face mask, venturi system and nasal cannulae)


Demonstrates how to deliver oxygen urgently (including reservoir mask, simple face mask, venturi system and nasal cannulae)


Describe how to escalate or de-escalate oxygen therapy in a step wise manner eg. nasal cannulae to face mask.


Lines and attachments:

Recognise different lines and their location relevant to local population (eg arterial lines, central line, vas-cath)



Identify enteral feeding tube in situ, whether it is connected to feed and whether the feed pump is running


Knows to discuss plans with nursing staff prior to moving or reposition a patient with NG feed running


Aware of events which can displace feeding tubes and to escalate accordingly


Describes how to check enteral feeding length and escalates if tube length has changed


Describe how to recognise dysphagia and an escalation plan including referral to SLT


Demonstrates how to assist patients with eating and drinking


Have an awareness of modified diets or thickened fluids in line with SLT recommendations



Demonstrate how to categorise neurological status using the AVPU scoring


Describe factors that may cause or contribute to delirium


Describes how to recognise delirium


Demonstrates how to complete a CAM-ICU score


Demonstrates an understanding of non-pharmacological management of delirium


Demonstrates knowledge of the Mental Capacity Act, when capacity assessment is indicated, how to assess capacity and when specialist communication support is required eg. referral to SLT



Demonstrates how to use pain faces or a similar visual analog scale


Demonstrates an understanding on the impact of pain on patient presentation eg. agitation


Demonstrates an understanding of the impact of pain medication on patient presentation eg. sedative effect



Demonstrates an understanding of RASS (or alternative sedation) scoring system


Able to access and read using ICU drug charts


Demonstrates an awareness of common ICU sedative medications


Demonstrates a basic knowledge of common ICU medications and their role e.g. sedatives, vasopressors, inotropes


Core competencies

Competency description Self assessment Senior assessment


Critical Illness Equipment and Pathophysiology:

Able to identify common equipment in the critical care unit:

  • Ventilators and associated oxygen delivery equipment (e.g. tubing and humidification);
  • Lines and tubes (e.g. cannula, CVC, arterial line, catheter, bowel management system, wound drains, chest drains);
  • Suction equipment;
  • Filtration equipment;
  • Additional equipment specific to local setting (e.g. ECMO);
  • Resources specific to Speech and Language Therapy assessment and intervention

Able to demonstrate clerking of critical care patient including:

  • Diagnoses and key admission events;
  • Past medical history;
  • Social History;
  • Investigations;
  • Vital signs and current status;
  • MDT assessments;

Aware of relevant neurological factors that may impact a patient’s ability to engage and participate:

  • Neurological diagnoses and terminology relevant to local population (e.g. trauma, neurosurgery, progressive neurological conditions, disorders of consciousness);
  • Neurological assessments used by critical care teams (e.g. GCS, AVPU, RASS);
  • Patient behaviours;
  • Presentations and assessment scores that would contraindicate Speech and Language Therapy input.

Aware of other relevant factors and diagnoses including:

  • Respiratory function;
  • Infection and sepsis;
  • Renal function and treatment (e.g. filtration) ;
  • ENT input;
  • Other diagnoses and interventions (e.g. cardiac, vascular, spinal).

Demonstrates knowledge of respiratory anatomy and physiology including:

Respiratory anatomy


The processes of breathing, ventilation and respiration


Pneumonias including CAP, HAP, VAP, aspiration pneumonia

  • Pneumothorax
  • Atelectasis
  • Effusions
  • Oedema
  • Consolidation
  • Pulmonary embolism
  • Chronic obstructive pulmonary disease (COPD)
  • Asthma
  • Acute respiratory distress syndrome (ARDS)
  • Breathing patterns (e.g. Cheyne-Stokes, abdominal, diaphragmatic breathing)
  • Hyperventilation and hypoventilation
  • Dyspnoea and tachypnoea
  • Inspiratory, expiratory, and biphasic stridor
  • Peak flow and vital capacity

Demonstrates knowledge of delivery devices and associated oxygen flow and concentration

  • Oxygen (concentration and flow)
  • Nasal cannula
  • High flow nasal cannula/Optiflow
  • Venturi Mask
  • Partial rebreather and non-rebreather

Demonstrates knowledge of respiratory failure and associated terminology

  • Type 1 Respiratory Failure (hypoxemia)
  • Type 2 Respiratory Failure (hypercapnia)
  • Respiratory acidosis and respiratory alkalosis
  • Arterial blood gas (ABG) and venous blood gas (VBG)
  • Arterial oxygen (PO2 or PaO2)
  • Arterial carbon dioxide (PCO2 or PaCO2)
  • Arterial oxygen saturation (Sa02)
  • Describes indications for initiation of CPAP (e.g. T1RF, pulmonary oedema, pneumonia, obstructive sleep apnoea)
  • Describes indications for initiation of NIV (BiPAP) (e.g. T2RF and COPD exacerbation)


Able to describe:

  • Normal ranges
  • Terminology for outside of normal range
  • Impact on patient presentation
  • Considerations for assessment and management

Examples of relevant biochemistry include:

  • Haemoglobin (Hb or Hgb) (anaemia, polycythaemia)
  • Platelets (thrombocytopaenia, thrombocytosis)
  • Iron (Fe) (iron deficiency anaemia)
  • White blood cells count (WBC or WCC)
  • Neutrophils (neutropenia, neutrophilia)
  • C-Reactive Protein (CRP)
  • Sodium (Na) (hyponatraemia, hypernatraemia)
  • Magnesium (Mg) (hypomagnesaemia, hypermagnesaemia)
  • Calcium (Ca) (hypocalcaemia, hypercalcaemia)
  • Potassium (K) (hypokalaemia, hyperkalaemia)


Aware of the key components of an endotracheal tube


Aware of common reasons for intubation with specific reference to local population.


Aware of key terminology and process used by the critical care team in association with intubation (e.g. sedation hold, cuff leak test).


Demonstrates basic knowledge of airway assessment tools: • Mallampati class 1-4 • Cormack-Lehane grade 1-4


Demonstrates an understanding of the impact of extended intubation on whole body systems (e.g. neurological, musculoskeletal, respiratory)


Demonstrates knowledge of the common complications and laryngeal injuries that result from intubation including:

  • Vocal fold mobility impairment
  • Granulation tissue
  • Ulceration
  • Oedema
  • Stenosis
  • Tracheomalacia
  • Odynophagia
  • Tongue weakness
  • Laryngospasm

Demonstrates knowledge of alternative causes of laryngeal dysfunction and utilises this knowledge to assist in different diagnosis including:

  • Neurological;
  • Surgical;
  • Infection.

Medications - demonstrates basic knowledge of the indications and contraindications for common medications that may impact a patient’s presentation including:

Antibiotics (e.g. Amoxicillan, Clarithromycin, Co-amoxiclav, Levoflaxin, Tazocin)


Benzodiazepines (e.g. Diazepam, Lorazepam, Midazolam)


Analgesics (e.g. Fentanyl, Morphine, Oxycodone, NSAIDs)


Anaesthetics (e.g. Propofol, Ketamine)


Antidepressants and anti-anxiety (SSRIs) (e.g. Sertraline, Citalopram, Fluoxetine)


Antipsychotics (e.g. Risperidone, Clozapine, Olanzapine, Haloperidol)


Anticonvulsants (e.g. Phenobarbital, Gabapentin)


Vasopressors (e.g. Norepinephrine/Noradrenaline, Epinephrine, Dopamine)


Inotropes (e.g. Digoxin)


Protein Pump Inhibitors (PPIs) (e.g. Omeprazole, Lanzoprazole, Pantoprazole)


Antifungals (e.g. Fluconazole, Nystatin)


Steroids (e.g. Dexamethasone)


Antiemetics (e.g. Odansetron, Metoclopramide, Domperidone)


Antimuscarinics (e.g. Hyoscine Hydrobromide, Atropine, Glycopyrrolate)


Other (e.g. Clonodine, Furosemide)



Demonstrates awareness of factors that can cause or contribute to delirium including:

  • Environmental;
  • Medication;
  • Patient specific physiology and diagnoses,

Aware of delirium assessment tools used in critical care (e.g. CAM-ICU) and interpretation of scoring and how communication disorders can impact scoring.


Demonstrates knowledge of frequent characteristics and behaviours of patients in delirium and can contribute to differential diagnosis of delirium from cognitive communication disorder, with consideration of similarities, differences, and likely course.


Considers impact of delirium in Speech and Language Therapy assessment, intervention, and recommendations.



Demonstrates knowledge of post intensive care syndrome (PICS), the impact of critical care weakness on communication and swallowing function, and an understanding of the impact of PICS on recovery trajectory.


Critical thinking and clinical reasoning

Demonstrates ability to use clerking information to determine appropriateness for Speech and Language Therapy input with consideration of diagnosis, medical acuity and trajectory. This could include, but is not limited to:

  • Neurological status
  • Respiratory status
  • Gastrointestinal function
  • Pain management, fatigue, mood and other factors
  • Wider treatment plan (e.g. upcoming surgeries, interventions, active versus palliative treatment goals, discharge plan)
  • Pre-admission presentation

Demonstrates ability to integrate clinical presentation and individual patient factors to diagnose communication disorders and make safe and appropriate recommendations and treatment plans


Demonstrates ability to liaise and negotiate with MDT members with different goals and recommendations to achieve optimal patient centred and safe care as required.


Evidence Based Practice

Aware of the main points covered in key national and international guidelines and can apply them to patients with Speech and Language Therapy needs as appropriate: GPICS; NICE CG83



Critical Illness Equipment and Pathophysiology:

Describes a basic understanding of gastrointestinal tract anatomy


Awareness of frequent gastrointestinal terminology relevant to local critical care setting, including but not limited to:

  • Ileus
  • Bowel obstruction
  • Types of hernias
  • Gastrointestinal bleeding
  • Haematemesis
  • Melaena
  • High aspirates
  • Malabsorption

Surgical feeding restrictions that may impact Speech and Language Therapy recommendations (e.g. free fluids)


Able to describe the basic function and key differences between feeding/drainage tubes how these tubes may impact Speech and Language Therapy (e.g. NGT, NJT, JEJ, PEG, RIG, Ryles)


Awareness of parenteral nutrition (PN) and factors to consider in dysphagia management for a patient on PN.


Tool for Assessment of Swallow

Demonstrates knowledge of local swallow screening tools with specific reference to any exclusionary criteria


Demonstrates knowledge of readiness for Speech and Language Therapy clinical bedside dysphagia assessment and contraindications for assessment including:

  • Respiratory function
  • Neurological function
  • Gastrointestinal function
  • Secretion management and suctioning requirements
  • Pre-admission swallow function
  • Overall medical trajectory and plan (e.g., active versus palliative management, planned surgeries and interventions)

Demonstrates ability to integrate investigations and findings into Speech and Language Therapy dysphagia management plans (e.g. CXR, Ba swallow, CT head)


Refers for or undertakes appropriate instrumental assessments at an appropriate time according to patient’s overall presentation


Liaises appropriately with MDT and advocates for further specialist input or investigation to inform dysphagia diagnosis and management (e.g. ENT, CT neck) as indicated.


Critical thinking and clinical reasoning

Demonstrates ability to integrate clinical presentation and individual patient factors to diagnose dysphagia and make safe and appropriate recommendations and treatment plans


Demonstrates ability to liaise and negotiate with MDT members with different goals and recommendations to achieve optimal patient centred and safe care as required.


Demonstrates ability to form clinical judgements that balance risk (e.g. severity of aspiration, presence of protective factors, medical stability) with quality of life. Decisions are patient centred with consideration of patient preferences and capacity.


Applies findings from instrumental swallow assessments and other investigations to develop robust Speech and Language Therapy management plans.


Working With Others: Swallow

Understands the specific contributions of MDT colleagues within their critical care roles and liaises with colleagues as appropriate to optimise swallowing function.


Able to advise the MDT of the impact of dysphagia on the patient pathway.


Provides opinion to and collaborates with the MDT on both pharmacological and non-pharmacological interventions that may improve swallow function.