Problem Solving: Services in the Pediatric Intensive Care Unit

QUESTION: I have a general question about providing services in the Pediatric ICU. It has made sense to me to provide support for the development of sucking and swallowing skills for infants in the NICU. Many of these babies are not even eligible for discharge until they are nipple feeding or at least stable on a feeding tube. But this seems different to me than the situation in the ICU. I’d like to know how this concept for babies translates to the ICU for older kids and adults.

If a person has lost swallowing skills due to illness, surgery or a traumatic brain injury it would seem to me that the individual would be pretty sick if he or she were in the ICU. It also makes intuitive sense to me that during the time in the ICU that the person’s physical body would be focused 100% on just getting well and more stable in physiological functions. Most of the friends and relatives I’ve seen in the ICU don’t have the energy or focus for an external swallowing rehabilitation focus. There also seems to be some natural return of function as their overall health improves. The therapy for swallowing seems to come later when the person is well enough to go to a step-down unit etc. With these observations, I don’t understand why a therapist would be assigned to work on swallowing function when the person is in the ICU. I’d appreciate it if you could help me understand the rationale for working with someone who is sick enough to be in the ICU. Thanks.

ANSWER: Our intensivists and nurses appreciate our involvement to evaluate, treat, provide consultation and education, and attend rounds to problem-solve the complex interaction of systems and their impact on swallowing safety and communication. The patients present with a wide variety of issues and etiologies, including cardio-respiratory, neuro, airway, GI, neuro-motor, and/or sequelae from prematurity that impact critical decisions that need to be made during their stay in PICU. The challenge of course is to provide our input and our services in the context of the infant’s/child’s ever changing medical status through very close interaction with the medical team and adjust our plan of care accordingly from day to day, moment to moment. We must carefully consider not only what to do, when to do it, but what not to do. Reflective thinking, caution and respect for the “bigger picture” must always prevail.

Our expertise can improve the likelihood that decisions made minimize adverse consequences and may indeed reduce LOS. That may mean helping the medical team to complete the differential and sort out key issues, evaluating a patient for readiness for direct therapy, assessing to help determine whether to feed orally and the safest way /diet to do so, or when not to feed orally but rather initiate SLP involvement to establish readiness, normalize the oral-sensory system during/after periods of NPO, and/or facilitate key components of oral-motor control/swallowing when medical stability permits, provide assessment of cognitive-communication skills that helps a physician to complete his neuro differential, direct therapy to improve skills and assist MD with prognosis, strategies for RNs to best communicate with the child or support the infant’s emerging communicative intent. We follow these infants and children as they transfer to units such as Pediatric Critical Care or Pediatric Rehab, and provide input regarding readiness for discharge and post-discharge needs. Family and staff education, some of it direct, some of it incidental, is a big part of our contribution to the infant’s/child’s care.

PICU, as well as NICU, are by far wonderful and fulfilling environments to work in, as we have the opportunity to be an essential part of the care team, learn something new every day through both these interactions with the team and our little patients and their families, and provide the unique input our training and expertise allow.


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