Problem-Solving with Catherine: Navigating Acute Care/PICU Practice Challenges

QUESTION: I am working with a team of non-dysphagia specialists because of shortage of SLP (not in the USA) in pediatric ICU (PT, nurses). When I arrived, I realized that they do everything wrong in SLP standards : start dysphagia exam too early on, speed dysphagia bedside exam with a bit of water, rely only on coughing to assess if dysphagia is present or not, do not do a single swallow FEES/VFSS, do not even know/care about silent aspiration, progress up very rapidly through textures when mastication is not yet possible in my opinion, give rapid directions to families and do not overwatch. Of course, they refer to SLPs for complicated cases, they are scared with or when they are unsure. We are left with the slowly recovering kiddos. they simply judge by overall recovery. If overall is fine, dysphagia is fine for them. But I feel they would be more complications in the adult population however with this type of approach. I am starting to question my stance on dysphagia eval among children in ICU. Is it way simpler than we may think? Do you have an opinion?

ANSWER: I would continue to use the evidence base as your guide, combined with your clinical expertise. Our PICU patients are often fragile but the adverse response to decisions or approaches that are not consistent with best practice may be silent, may increase need for respiratory support without adverse overt events and the child may “run under the radar” for a while. That doesn’t mean you abandon your critical thinking. Not sure if this is a travel assignment or they are the newly added team members, but you will need to decide how best to advocate for your peds patients and to reconcile this risk. That means perhaps having a conversation with them that is respectful, offering practice guidelines by ASHA or research evidence, thinking about how to gain administrative support to foster collaboration and best practice in dysphagia, and what your next steps will be to assure there is appropriate care and colleagues “do no harm” which you likely have an obligation to address via risk management. Should something adverse occur and there is litigation, your documentation and whether it and your actions were consistent with best practice would be scrutinized and determined by an expert pediatric acute care SLP. Always manage patients and document as if litigation is possible, because it is. Trust your instincts. It’s a really challenging situation but best to take control of it in one way or another versus being a bystander when it may affect your professional practice and patient long-term outcomes. That may indeed be leaving if the risk to you is not acceptable, which is clearly possible based on what we know. I hope this is helpful.


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