Speech and Language Therapy EPA4 Assesses and manages the ventilator-dependent tracheostomised patient

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

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

Demonstrates positive patient identification and awareness of allergies

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

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

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

Awareness of peer support and psychological support

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

Demonstrates how to view results and imaging on local IT systems

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

Compliant with Manual Handling training as per local trust policy.

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

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

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.

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

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).

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

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

• 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.

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.

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

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)

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.

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

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

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.

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.

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.

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.

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).

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

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

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

Able to describe the key physiological indicators for mechanical ventilation.

Able to describe the impact of mechanical ventilation on swallowing and communication in both the short and long term.

Aware of key terminology used in relation to ventilation including:

• Pressure support
• Peak airway pressure (PIP)
• Inspiratory plateau pressure
• Mean airway pressure
• Positive end-expiratory pressure (PEEP)
• Inspiratory time (Ti)
• Expiratory time (Te)
• Tidal volume (VT)
• I:E ratio
• Expiratory tidal volume (VTE)

Aware of the modes of invasive ventilation determined by respiratory function and medical acuity, with reference to locally used terminology (may vary by ventilator brand) including:

• Continuous mandatory ventilation (CMV)
• Assist/control ventilation (AC)
• Synchronized intermittent mandatory ventilation (SIMV)
• Pressure control (PC)
• Pressure regulated volume control (PRVC)
• Pressure support ventilation (PSV)
• Airway pressure release ventilation (APRV)

Able to identify necessary information regarding mode type and settings on local ventilators and on local notes system.

Aware of ventilator weaning protocols used locally (e.g. spinal cord injury weaning protocols), and impact on Speech and Language Therapy assessment and management and MDT weaning plans.

Able to identify key ventilator parameters that indicate readiness for trial of cuff deflation and Passy Muir Valve (PMV) with specific reference to:

• Ventilator mode
• FiO2
• Pressure support
• Positive end-expiratory pressure (PEEP)

Aware of need to override ventilator alarms to allow for air leak for PMV trials.

Able to use ventilator parameters to assess for adequate upper airway with cuff deflation (in addition to other observations and parameters used with all tracheostomy patients and covered in tracheostomy competency documents). Specific reference should be made to:

• Expiratory tidal volume changes (VTE)
• Peak airway pressure changes (PIP)
• Capnography trace

Able to advise MDT on appropriate management if inadequate upper airway is suspected (e.g visualisation of upper airway, tracheostomy downsize, timing of further cuff down trials).

Aware of ventilator adjustments that may increase patient comfort with cuff deflation and PMV trials with consideration of FiO2, PEEP and tidal volume (VT).

Refers for or undertakes instrumental swallowing assessments at an appropriate time and can integrate of assessments to contribute to robust tracheostomy weaning plans or dysphagia management plans.

Integrates learning from EPAs 1, 2 and 3 and patient’s clinical presentation, diagnoses, acuity, and trajectory to provide a robust ventilator and tracheostomy weaning plan in collaboration with MDT colleagues that optimises a patient’s communication and swallow function.