Speech and Language Therapy EPA3 Assesses and manages the non-ventilated tracheostomised patient

This EPA includes:

  • Determines suitability for Speech and Language Therapy input for tracheostomy weaning.
  • Integrates tracheostomy presentation with wider clinical presentation to develop a tracheostomy weaning plan in collaboration with MDT colleagues.
  • Uses knowledge of dysphagia and communication assessment and intervention and applies this to patients with a tracheostomy to make safe and appropriate recommendations.

Context:

  • Adult patients in the critical care setting with a tracheostomy on room air or supplementary oxygen only.

Limitations:

  • This EPA does not apply to patients on ventilator support at the time of Speech & Language Therapy intervention.
  • Speech and Language Therapy EPA 1 and 2 must be completed prior to undertaking EPA 3.

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. Speech and Language Therapy EPA 2: Assesses and manages swallowing disorders in critical care
  4. Clinicians must be either fully competent or undertaking competencies with supervision as per local trust policy and either:
    • The Royal College of Speech and Language Therapists Tracheostomy Competency Framework
    • Local Speech and Language Therapy tracheostomy competency documents
  5. Additional C3Framework Speech and Language Therapy Domains:
    • Critical Illness Equipment and pathophysiology: Tracheostomy
    • Tracheostomy
    • Working with Others: Tracheostomy
    • Evidence Based Practice: Tracheostomy
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

Safety

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

 
 

Orientation:

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

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

 
 

Documentation

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

Teamwork:

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

Airway:

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

 
 

Oxygen:

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)

 
 

Nutrition:

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

 
 

Delirium:

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

 
 

Pain:

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

 
 

Sedation:

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

Communication

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)
 
 

Biochemistry

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)
 
 

Intubation

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)

 
 

Delerium

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.

 
 

PICS

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.

 
 

Tools for Assessment of Communication

Integrates clerking information, medical investigations, and current status to inform selection and application of appropriate communication assessment including:

  • Informal and screener assessments
  • Formal language, cognitive communication, and motor speech assessments
  • Functional assessments
  • Self-rating scales
  • Perceptual voice assessments e.g. GRBAS scale
  • Assessments of disorders of consciousness e.g. WHIM, CRS
  • Communication history questionnaire
  • Assessment for AAC provision or onward referral
 
 

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

 
 

Communication strategies

Able to develop appropriate management plans incorporating individual patient factors (e.g. sourcing AAC, delivering communication therapy, or onward referral to appropriate services)

 
 

Able to provide appropriate strategies and advice to support MDT, family, and friends in communicating with patients with communication disorders

 
 

Able to select and source low-tech and high-tech communication aids with consideration of patient preference, cognition, language and physical function including:

  • Picture charts
  • Alphabet charts
  • Visual charts such as pain scales
  • Whiteboard and pen
  • iPads, phones and apps
  • Additional accessibility aids (e.g. switches, call bells)
 
 

Aware of referral criteria and process for local specialist AAC service

 
 

Able to identify when a patient would benefit from Speech and Language Therapy support for capacity assessments and is able to use appropriate verbal, written and picture aids to support as needed.

 
 

Aware of patient centred local initiatives that support communication (e.g. ‘This is me’ boards, patient journey diary)

 
 

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.

 
 

Working with others: communication

Understands the specific contributions of MDT colleagues within their critical care roles and liaises with colleagues as appropriate to optimise patients’ communication

 
 

Able to advise the MDT of the impact of communication disorders on the patient pathway

 
 

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

 
 

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

 
 

Swallowing

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.

 
 

Self-ventilating tracheostomies

Critical Illness Equipment and Pathophysiology

Aware of location of tracheostomy equipment within local unit (e.g. spare suction catheters, spare tracheostomy tubes, one-way valves, syringes, safety signage and equipment).

 
 

Tracheostomy Management

Clinicians must be either fully competent or undertaking competencies with supervision as per local trust policy and either: a. The Royal College of Speech and Language Therapists Tracheostomy Competency Framework b. Local Speech and Language Therapy tracheostomy competency documents

 
 

Demonstrates a knowledge of the effects of short- and long-term tracheostomy on communication, swallowing and airway.

 
 

Demonstrates a knowledge of the risk and benefits of tracheostomy manipulation on communication, swallowing and tracheostomy weaning.

 
 

Integrates knowledge of patient’s tracheostomy-related presentation with wider clinical presentation including diagnoses, acuity, medical trajectory, and wider treatment plan to develop a safe and appropriate tracheostomy weaning plan in collaboration with MDT colleagues.

 
 

Integrates knowledge of communication and swallow assessment and intervention in the critical care setting (obtained in EPA 1 and EPA 2) and can apply this to patients with a tracheostomy to make safe and appropriate recommendations for eating/drinking and communicating.

 
 

Optional if applicable to setting: Demonstrates knowledge of process of Above Cuff Vocalisation (ACV), indications, contraindications and side effects of ACV and local guidelines if applicable

 
 

Working with others: Tracheostomy

Aware of key tracheostomy MDT members and their role in tracheostomy management including critical care medical team, nursing staff, physiotherapy, and ENT.

 
 

Collaborates with MDT members to develop a tracheostomy weaning plan with consideration of patient’s communication, swallow and laryngeal function and can advocate for adjustments to optimise weaning based on Speech and Language Therapy findings.

 
 

Provides opinion to and collaborates with the MDT on both pharmacological and non-pharmacological interventions that may improve tracheostomy wean

 
 

Evidence Based Practice

Aware of the main points covered in key national and international guidelines that applies to tracheostomy patients including: FICM/ICS Tracheostomy Guidance; NTSP.

 
 

Demonstrates knowledge of local tracheostomy guidelines or policies pertaining to tracheostomies and how to locate on local systems.

 
 

Able to describe how local guidelines impact may impact Speech and Language Therapy management of a tracheostomised patient