key: cord-0755358-kexf7wsw
authors: Freeman-Sanderson, Amy; Ward, Elizabeth C.; Miles, Anna; de Pedro Netto, Irene; Duncan, Sallyanne; Inamoto, Yoko; McRae, Jackie; Pillay, Natasha; Skoretz, Stacey A.; Walshe, Margaret; Brodsky, Martin B.; Archer, Sally K.; Baker, Sonia; Bergström, Liza; Burns, Clare L.; Cameron, Tanis; Cimoli, Michelle; Clayton, Nicola A.; Clunie, Gemma; Cole, Therese; Dawson, Camilla; Dikeman, Karen; Duggan, Brooke; Engelbrecht, Leanie; Langton-Frost, Nicole; Hemsley, Bronwyn; Kalf, Hanneke; Kazandjian, Marta; Lakha, Sunaina; Marvin, Stevie; McIntyre, Melanie; Puntil-Sheltman, Jo; Ribamar do Nascimento Junior, José; Suiter, Debra M.; Sutt, Anna-Liisa; Wallace, Sarah; Zaga, Charissa J.
title: A consensus statement for the management and rehabilitation of communication and swallowing function in the ICU: A global response to COVID-19
date: 2020-11-07
journal: Arch Phys Med Rehabil
DOI: 10.1016/j.apmr.2020.10.113
sha: 8a28faf5931406a93b038776824138fd8663d1d5
doc_id: 755358
cord_uid: kexf7wsw

Objective To identify core practices for workforce management of communication and swallowing functions in COVID-19 positive patients within the ICU. Design A modified Delphi methodology was utilized, with 3 electronic voting rounds. AGREE II and an adapted COVID-19 survey framework from physiotherapy were used to develop survey statements. Sixty-six statements pertaining to workforce planning and management of communication and swallowing function in the ICU were included. Setting Electronic modified Delphi process. Participants 35 speech-language pathologists (SLPs) from 6 continents representing 12 countries. Interventions Not applicable. Main Outcome Measures The main outcome was consensus agreement, defined a priori as ≥70% of participants with a mean Likert score ≥7.0 (11-point scale: “0” = strongly disagree, “10” strongly agree). Prioritization rank order of statements in a 4th round was also conducted. Results SLPs with a median of 15 years ICU experience, working primarily in clinical (54%), in academic (29%) or managerial (17%) positions, completed all voting rounds. After the third round, 64 statements (97%) met criteria. Rank ordering identified issues of high importance. Conclusions A set of global consensus statements to facilitate planning and delivery of rehabilitative care for patients admitted to the ICU during the COVID-19 pandemic were agreed by an international expert SLP group. Statements focus on considerations for workforce preparation, resourcing and training, and the management of communication and swallowing functions. These statements support and provide direction for all members of the rehabilitation team to use for patients admitted to the ICU during a global pandemic.

SLPs with a median of 15 years ICU experience, working primarily in clinical (54%), in 29 academic (29%) or managerial (17%) positions, completed all voting rounds. After the third 30 round, 64 statements (97%) met criteria. Rank ordering identified issues of high importance. AGREE II 36 and an adapted framework of questions 29 were used to develop tools for 97 consensus ratings. The statements contained in the survey were developed from guidelines 98 and published research accessible from web searches, speech-language pathology, 99 otolaryngology, and intensive care societies published earlier than April 8, 2020 in 100 conjunction with expert opinion from the authorship group. A pre-study virtual meeting was 101 held on April 7, 2020 to outline study aims, methods, and timeline. The group was then 102 asked to: 1) individually and anonymously review and comment on the 72 draft statements 103 planned for inclusion in the survey and 2) contribute up to 3 additional statements for 104 consideration. In total, the group provided 22 additional statements and after duplicates were 105 removed, 15 statements were included. The PIs consolidated and refined the statements 106 further to exclude statements outlining standard practice, with the final set of 66 statements 107 included in the May 11, 2020 distribution. The Delphi process convenes a group of experts for decision-making during an 111 iterative process of questions, anonymous responses, and controlled feedback to the 112 respondents. 37 This study involved 3 rounds of modified Delphi consensus voting. The online 113 platform Qualtrics (2019) was used to collect both the demographic and questionnaire data 114 (Qualtrics, https://www.qualtrics.com, Provo, UT) . Each round, participants were reminded 115 that the content was confidential and they were not to share, discuss, or distribute any 116 content. Participants were further reminded to respond using his/her own knowledge and 117 expertise independent of his/her country, place of business, affiliation, society membership, 118 guideline, or other external guidance. 119

Each participant was sent the link to Round 1 on May 11, 2020, categorized into 3 120 domains: 1) Workforce planning, preparation, and management, including statements (n=25) 121 relating to organization of personnel and resources to address clinical surge and distribution 122 across service lines, 2) Management of communication function, which considered the 123 organization and resources for assessing and promoting effective patient understanding and 124 expression, regardless of whether the patient was intubated with mechanical ventilation, 125 post-extubation, or not intubated (n=15 statements), and 3) Management of swallowing 126 function (n=26 statements), which considered the organization and resources for assessing 127 and promoting safe and effective swallowing (see Supplemental Material 1). An 11-point 128 Likert scale was used to rate each statement (0=strongly disagree, 10=strongly agree). 129

Consensus agreement was operationally defined a priori as ≥70% 29,38,39 of the participants 130 with a mean Likert score ≥7.0 for any statement. 131

In Round 1, participants were asked to rate agreement with all 66 statements. During 132 Rounds 2 and 3, participants were asked to rate only those statements that failed to meet 133 consensus on Round 1 or 2 respectively, and explain why they chose that rating for each 134 statement. In both Round 2 (beginning May 15, 2020) and 3 (beginning May 19, 2020) the 135 mean score and standard deviation (obtained from previous round) for any included 136 statement was provided as feedback. Additionally, Round 3 feedback included two 137 anonymous remarks each from participants who scored statements ≤2 and ≥8 from Round 2 that represented reasons for why these "extreme" scores were chosen. These remarks were 139 included as feedback for Round 3 and chosen for inclusion by the PIs. All participants were 140 advised in advance of the planned dates and timing of each rounds of consultation, with 141 each round sent to participants with 96 hours to complete. 142

An exploratory fourth round (beginning May 24, 2020) of anonymous voting and 143 unrelated to the modified Delphi procedures was added to rank order priorities within each of 144 the 3 domains of questions. Statements that scored a mean Likert score ≥9 and ≥90% 145 consensus were included. 146 147

Descriptive statistics were used to analyze demographic and statement data. 149

Differences between groups were analyzed using the Kruskal-Wallis H test. Round 2 included the 5 items that failed to meet consensus, and agreement was reached for 171 2 of the 5 statements. Round 3 contained 3 statements, with consensus reached for 1. At the 172 end of 3 modified Delphi rounds, 64/66 (97%) statements reached consensus (Table 1) 

In Round 1, 14/15 (93%) communication statements reached consensus. The 185 statement that did not reach consensus was: "Speaking (i.e., oral communication) is a low 186 risk aerosol generating procedure (AGP)" (M=5.9, SD=2.9, 49% consensus). In both Rounds 187 2 and 3, this statement failed to reach consensus (Round 2: M=5.8, SD=2.8, 57% 188 consensus; Round 3: M=5.9, SD=2.8, 63% consensus). 189

190

In Round 1, 23/26 (88%) of statements reached consensus. The 3 statements that 192 did not reach consensus were: 1) "Assessment of the gag reflex is considered an aerosol 193 generating procedure (AGP). Assessment should be discussed with the treating ICU team" 194 (M=7.1, SD=3.0, 66% consensus), 2) "A voluntary cough (i.e., asking the patient to cough) is 195 considered an aerosol generating procedure. Assessment should be discussed with the 196 treating ICU team" (M=7.2, SD=3.1, 63% consensus), and 3) "Swallowing therapy tasks that 197 are aerosol generating tasks should be provided to patients" (M=6.9, SD=2.7, 57% 198 consensus). After Round 2, participants only agreed that a voluntary cough is an AGP 199 (M=7.7, SD=2.6, 86% consensus), whereas "testing the gag reflex" (M=6.9, SD=2.5, 71% 200 consensus) and "swallowing therapy tasks" (M= 6.8, SD=2.6, 63% consensus) failed to 201 reach consensus. At the end of Round 3, "swallowing therapy tasks" reached consensus 202 (M=7.3, SD=2.7, 77% consensus), but "testing the gag reflex" did not reach consensus 203

A post-hoc analysis was completed to address the 17 statements that contained an 207 additional phrase: "...should be discussed with the treating ICU team" (or similar). All of 208 these statements regarded AGPs. On June 17, 2020, a questionnaire was distributed, 209 specifically removing this phrase from each statement (supplemental material 2). Two additional questions asked participants to average how frequently and how much weight the 211 "discuss with the treating ICU team" phrase influenced the ratings across all questions 212 containing this phrase using a 0-10 scale (i.e., 0=never; 10=always). There was 100% 213 (35/35 participants) response rate. Consensus was reached on 15/17 (88%) statements 214 using previously stated criteria for consensus. The 2 statements that did not reach 215 consensus were: 1) "Swallowing/feeding trials may be considered an aerosol generating 216 procedure" (M=7.4, SD=2.7, 66% consensus) and 2) "Videofluoroscopic swallow studies 217 (VFSS) may be considered an aerosol generating procedure" (M=7.5, SD=2.6, 66% 218 consensus). Finally, for the phrase "...should be discussed with the treating ICU team" (or 219 similar), participants reported a mean of 7.3 (SD=2.7) for how frequently they regarded the 220 phrase and a mean of 6.5 (SD=2.3) for how much weight they placed on the phrase. 221 222 Rank Order Results 223

Thirty-three statements resulted in a mean ≥9.0 for ≥90% of participants during 224 voting rounds. These statements were ranked in priority order across the three survey 225 sections ( continue to receive appropriate and timely swallow assessments and rehabilitation without 250 risking the health of the health professionals (Table 3) . 251

Participants agreed that rehabilitation occurs within and beyond the ICU. As a group, 252 participants' highest ranked item for the workforce planning and management section, was 253 the need to identify SLPs with specific skills for the provision of communication and 254 swallowing rehabilitation in ICU patients. To bolster extent and continuity of care, a 255 multidisciplinary team inclusive of physicians, advanced-practice providers (e.g., nurse 256 practitioner, physician assistant), nurses, respiratory therapists, physical therapists, 257 occupational therapists, dieticians, and social workers is also necessary, but this is only a 258 first step. 20 Strategic planning, including contingencies for service delivery of independent 259 and specialized clinical practices within the changing nature of the pandemic, should be 260 considered. In fact, as an autonomous clinical provider, the weight and frequency of how 261 SLPs regarded the phrase: "…should be discussed with the treating ICU team" influenced 262 their ratings. Prioritizing staffing is paramount to deliver rehabilitation services that will 263 reduce morbidities and to promote improved functional outcomes in survivors of critical Despite efforts to ensure rigorous methodology, the study has limitations that need to 296 be considered. Recruitment was through a network of experienced ICU clinicians and clinical 297 researchers, and hence may not represent the views of all clinicians. Also, it is 298 acknowledged that although 12 countries were within the participant cohort, the majority 299 (66%) came from 3 specific countries (i.e., Australia, United Kingdom, United States). 300

However, both between and within these countries, variation is evident with SARS-CoV-2 301 infection rates, pandemic response, and clinical practice. 50 As such we believe each 302 participating clinician brought differing perspectives and experiences to the study, 303 independent of demographic or country composition. 304

Governing bodies and professional organizations were frequently updating opinions 305 and offering new guidance for safety, clinical procedures, and clinical management. To this 306 point, the World Health Organization (WHO) declared COVID-19 a pandemic on March 11, 307 2020. 51 This questionnaire was finalized April 14, 2020 and distributed with ethics committee 308 approvals on May 11, 2020, during the time when the evidence base was emerging. 309

Generally speaking, survey instruments are quick and responsive to obtaining new 310 information. In the rapidly changing environment of a new pandemic, changes in 311 understanding SARS-CoV-2 continued to drive daily policy changes. 52-54 These changes 312 may not have been updated between the questionnaire's development and its distribution. 313

Global dissemination and relative acquisition of the latest information may not have been 314 equal, potentially leading to differing professional opinions on these two AGP statements. 315

Moreover, we were unable to determine whether the variable opinions among participants 316 was a reflection of regional differences, general ICU experience, or service experience 317 during the COVID-19 pandemic. 318

Despite the global variability that is known to exist with COVID-19 infection rates and 319 the personal experiences of clinicians in each service and each country, the current study 320 was able to obtain consensus on all but 2 of the items. Because of this, we believe the 321 current findings objectively represent a group of professionals with differing experiences, but 322 who maintain a unified mindset and approach to the management, assessment, and 323 treatment of communication and swallowing management for patients in ICU diagnosed with 324 COVID-19. Further research is need to explore regional and country needs with the 325 changing nature of COVID-19. 172 5 Cuff deflation is an aerosol generating procedure. Communication procedures for patients with a tracheostomy that require cuff deflation (e.g., speaking valves, leak speech) during mechanical ventilation should be discussed with the treating ICU team. 159 6 Cuff deflation is an aerosol generating procedure. Communication procedures for patients with a tracheostomy that require cuff deflation (e.g., speaking valves, leak speech) without mechanical ventilation should be discussed with the treating ICU team. 147 7 Above cuff phonation is an aerosol generating procedure. Management and use should be discussed with the treating ICU team. 129 8 Communication procedures for patients with a stoma (i.e., laryngectomy including voice prostheses) should be discussed with the treating ICU team. 97 9 Videofluoroscopic swallow studies (VFSS) may be considered an aerosol generating procedure. Assessment should be discussed with the treating ICU team.

Managing extreme workloads / influx of patients 2 Review of current caseload service delivery to identify capacity for increased service provision to higher acuity and increased clinical demand.

Staff should meet regularly with ICU staff (i.e., physicians, nurses) to determine indications for swallowing management in patients with (or suspected) COVID-19.

Specialist training and staff well being 5 Identify staff with ICU-specific clinical skills in relation to communication, swallow, and tracheostomy patient management.

Consider staff training needs for provision of rehabilitation services post-ICU discharge (i.e., post intensive care syndrome; PICS) Communication accessibility 7 Access to resources (e.g., glasses, hearing aids, call bells, AAC) to enable increased patient communication.

Consider additional resources (including training) for the acquisition of telehealth capabilities.

Swallow intervention accessibility 5 Patients should be supported to independently complete aspects of swallow rehabilitation as able.

Swallowing therapy tasks that are not aerosol generating tasks should be provided to patients.

NB: Some statements crossed over two themes 3

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Role of the multidisciplinary 399 team in the care of the tracheostomy patient

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The authors also wish to acknowledge and thank Peter J.Thomas for his guidance in developing this research.

Total Rank Score Rank Staff should meet regularly with ICU staff (i.e., physicians, nurses) to determine indications for swallowing management in patients with (or suspected) COVID-19. 322 1 Cuff deflation is an aerosol generating procedure. Swallowing procedures for patients with a tracheostomy that require cuff deflation (e.g., speaking valves) during mechanical ventilation should be discussed with the treating ICU team 240 2 Cuff deflation is an aerosol generating procedure. Swallowing procedures for patients with a tracheostomy that require cuff deflation (e.g., speaking valves) without mechanical ventilation should be discussed with the treating ICU team 231 3 Flexible endoscopic evaluation of swallowing (FEES) is considered an aerosol generating procedure. Assessment should be discussed with the treating ICU team. 227 4 Patients should be supported to independently complete aspects of swallow rehabilitation as able.217 5 Non-invasive ventilation (e.g., high flow nasal oxygen, BiPAP) is considered an aerosol generating procedure. A swallowing assessment in this context should be discussed with the treating ICU team. 210 6 Patients should be encouraged to self-feed where able. 210 6 Swallowing therapy tasks that are not aerosol generating tasks should be provided to patients. 208 8 Videofluoroscopic swallow studies (VFSS) may be considered an aerosol generating procedure. Assessment should be discussed with the treating ICU team. 183 9 Cleaning non-invasive equipment (e.g., stethoscopes, flashlights, ultrasound) between patients should be discussed with the ICU staff due to risk of cross contamination and healthcare worker infection. 167 10 Respiratory muscle strength training (i.e., EMST and IMST) is considered an aerosol generating procedure. Implementation should be discussed with the treating ICU team. 95 11 3