By: Ashley Logan, MS, CCC-SLP, BCS-S, CLT, San Antonio Military Medical Center
Hospitals can range in size from a small rural hospital with potentially fewer than 10 beds to large-scale trauma centers with greater than 500 beds. The patient population ranges from birth through age 99+, although some hospitals have separate pediatric and adult therapists who split up the inpatients by age (birth through 18 and 18 through 99+). Many hospitals have critical care (ICU) floors, transition units, and/or step-down medical floors where patients require less monitoring from both staff and machines. Speech-language pathologists (SLPs) are active at all levels of care and can even complete evaluations in the emergency department depending on policies at the individual hospital. Evaluations often occur at the bedside with whatever materials can be carried in by the SLP (and cleaned prior to next patient use), with the exception of videofluoroscopic swallow studies (VFSS), which are done in radiology.
Caseloads can range from as few as one to two patients in smaller hospitals to caseloads of greater than 30 to 40 in larger hospitals. SLPs are not expected to see all 30 to 40 patients per day; rather we tend to see patients in the order of acute need: new consults, patients due for repeat evaluations, therapy, etc. Staffing at hospitals in the SLP department can have varying ranges to match patient need, and often the SLP in the acute care setting has to ensure he/she is educating staff regarding the medical benefits of SLP consultation in the acute setting to ensure consults are being appropriately entered for patients who may have a speech-language, cognition, voice, airway, or swallowing need. Given the high demand and fast-paced nature of acute care, hospitals require SLPs to be proficient in all areas of service delivery. These clinicians need to be able to work quickly and independently to deliver medically necessary information ahead of patient discharge.
Patients who require post-acute care stays in rehabilitation facilities often stay in the hospital for a minimum of three days. Those with more critical injuries and/or placement challenges may stay much longer, with some patients staying a number of months in the hospital prior to discharge. In these instances, patients may complete the entire course of therapy with an SLP prior to ever leaving acute care. Given the multiple levels of medical acuity within the hospital, some patients may already have been in the hospital weeks to months prior to becoming appropriate for SLP evaluation and intervention. There is a wide range of patient presentations and post-evaluation needs across the age ranges and diagnoses.
Procedures often performed by the SLP in the hospital setting:
- Clinical swallow evaluations
- Fiber optic evaluation of swallowing (FEES)
- VFSS evaluations
- Speech-language-cognition evaluations
- Trach and vent care, speaking valve (PMV) evaluations
- Speech-language-cognitive-swallow therapy
- Voice-related evaluations and therapy are often deferred to outpatient; however, if poor glottic closure is contributing to aspiration, glottic closure activities involving voicing may be initiated while still in the hospital as a part of swallow intervention.
Patients often seen in acute care:
- Traumas (motor vehicle accidents, various other traumatic injuries)
- Post-operative head and neck surgeries (cancer, anterior cervical discectomy and fusion [ACDF] spinal procedures)
- Prolonged intubations (greater than 48 hours)
- Chronic obstructive pulmonary disease (COPD) exacerbations
- Aspiration pneumonia
- Traumatic brain injuries
- Advanced disorders and end-of-life care (dementia, Parkinson’s, ALS, MS, etc.)
Additional resources for SLPs getting started in acute care can be found here: https://www.asha.org/slp/healthcare/start_acute_care/.