SLP Guiding Principles
The Infection Prevention and Control (IPAC) at the University Health Network have been working with our Speech Language Pathologists (SLPs) to provide guidance for SLP specific tasks during this COVID-19 pandemic, including the use of Personal Protective Equipment (PPE).
Please note that this is an evolving situation and this webpage will be updated as new information becomes available.
During this COVID-19 pandemic, we should be very cautious about swallowing examinations all together. SLPs should undertake a point-of-care risk assessment to determine the need and appropriateness of conducting a swallowing examination. If a swallowing examination is deemed necessary, one must ensure appropriate precautionary measures are in place to provide optimal care to the patient, while minimizing the risk of transmission.
The Dysphagia Research Society has called attention to the emerging international consensus that COVID-19 may be spread not only via droplets and contact with contaminated surfaces but also via airborne transmission (DRS, 2020). This has drawn further review of Aerosol Generating Procedures (AGP), which are defined as procedures that have the potential to create aerosols and have been demonstrated to increase the risk of airborne transmission (Public Health Ontario, 2020). According to the Center for Disease Control (CDC), “There is neither expert consensus, or sufficient supporting data, to create a definitive and comprehensive list of AGPs for health care settings” (CDC, 2020).
During a swallow assessment there is a high risk of triggering a cough reflex, which may be an unpredictable source of aerosols. Therefore, swallowing assessments, both non-instrumental and instrumental, have the potential to be AGPs and precautionary measures should be taken (ASHA, 2020; DRS, 2020; ESSD, 2020; SAC, 2020; RCSLT, 2020).
Performing a Bedside Swallow Assessment
Please see this link below for our recommendations on how to reduce the risk of COVID-19 transmission during a Clinical Bedside Swallow Assessment.
Performing a Videofluoroscopy
In our facility, we have decided to be more selective in the patients we choose to take to videofluoroscopy, acknowledging that when assessment is limited to non-instrumental exams, management will be a common denominator and perhaps overly conservative.
In addition to the risk of triggering a cough reflex during a videofluoroscopy, which can be an AGP, there is also a high risk of transmission of the virus while moving the patient to and from the radiology suite (Namasivayam-MacDonald & Riquelme, 2020). In our case, a videofluoroscopy involves a journey through a set of elevators and tunnels to the nearby acute care hospital, or, for patients at our other campuses, a vehicle transfer. We would prefer to limit these transfers if possible.
In general, the guidance we are following to determine urgent priorities for VFSS across all our corporate facilities (acute and rehab) is below:
- Symptoms of aspirations (i.e. cough & choking with p.o intake at bedside, unable to identify a “best” texture in non-instrumental exam)
- Dysphagia management is discharge-limiting (i.e. feeding tube removal needed for discharge to next level of care/home)
- Patient has documented signs of aspiration on imaging (i.e. CXR/CT shows aspiration)
- Patient is currently diagnosed with aspiration pneumonia, and there is a reason to suspect oropharyngeal dysphagia as the cause
- For outpatients, significant weight loss (>10% in 6 months) or significantly decreased p.o. intake related to current diet texture
- On a clinical trial (i.e. cancer trial) with oral targeted therapy
Special Videofluoroscopy Considerations
1. Videofluoroscopy is a potential AGP due to the coughing that can occur during p.o. intake (ASHA, 2020; DRS, 2020; ESSD, 2020; SAC-OAC, 2020; Vergara, et al., 2020).
2. Videofluoroscopy may enable greater overall physical distancing between the clinician and the patient compared to FEES, however, the need for patient transport to a fluoroscopy suite and requirement for more personnel (i.e. SLP, radiologist, radiology technician) must be considered (Fritz, et al., 2020).
3. Recommendations to reduce risk of transmission during VFSS
i) Transport to/ from fluorosuite guidelines:
- Patients should wear a face mask during transport
- Trach patients should wear a mask over their trach and a mask on their face during transport. (American Academy of Otolaryngology-Head and Neck Surgery, 2020)
ii) SLPs should always conduct a point-of-care risk assessment to determine appropriate PPE required, however, in general the following is recommended:
- Unknown or COVID- patients (w/ no other precautions): Hand Hygiene + Surgical Mask + Eye protection + Gown + Gloves
- PUI/COVID+ patients: Hand Hygiene + N95 mask or higher level respirator + Eye protection + Gown + Gloves
iii) Access to appropriate equipment sanitization
iv) Limit number of personnel in fluorosuite to what is absolutely necessary
v) Encourage patient to self-feed if able
vi) Stand away and to the side of the patient if possible during feeding trials
vii) Consider the risks/ benefit of videofluoroscopy for patients with known behavioural challenges – i.e. spitting, biting, yelling, patients with visible drooling/ excess secretions that may become airborne or require suctioning during videofluoroscopy
viii) Consider what strategies might be contraindicated during videofluoroscopy due to increasing the generation of aerosols (i.e., avoiding super supraglottic)
ix) Use of an IQAir HealthPro (Incen AG) air filter with HEPA class H13 filtration system is recommended in radiology suite setup for MBSS, if available (Soldatova, L et al., 2020)
x) For PUIs and COVID+ patients:
- Defer until negative test result if possible
- Discuss with team appropriateness and urgency
- If using VFSS with a COVID + patient, plan to do your study at the end of the day for room cleaning
- Suggested PPE includes: N95 mask or higher level respirator, eye protections, gloves and a gown.
American Speech- Language-Hearing Association. (2020). ASHA guidance to SLPs regarding aerosol generating procedures. https://www.asha.org/SLP/healthcare/ASHA-Guidance-to-SLPs-Regarding-Aerosol-Generating-Procedures/
American Academy of Otolaryngology-Head and Neck Surgery. Guidance for return to practice for otolaryngology-head and neck surgery. Available at: https://www.entnet.org/sites/default/files/guidance_for_ return_to_practice_part_1_final_050520.pdf. Accessed November 12, 2020. 60.
Centres for Disease Control and Prevention . (2020). Clinical Questions about COVID-19: Questions and Answers.https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.htmlCDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Finfection-control-faq.html
Dysphagia Research Society. (2020). COVID-19 information and resources: Risk management for AGPs for dysphagia care. https://www.dysphagiaresearch.org/general/custom.asppage=COVID19AGPs
European Society for Swallowing Disorders (ESSD). (2020) European Society for Swallowing Disorders ESSD commentary on dysphagia management during COVID pandemia. https://worldswallowingday.org/essd-guidelines-on-dysphagia-during-covid-19
Freeman-Sanderson A, Ward EC, Miles A, de Pedro Netto I, Duncan S, Inamoto Y, McRae J, Pillay N, Skoretz SA, Walshe M, Brodsky MB, On behalf of the COVID-19 SLP Global Group, A consensus statement for the management and rehabilitation of communication and swallowing function in the ICU: A global response to COVID-19, ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION (2020), doi: https://doi.org/10.1016/j.apmr.2020.10.113.
Fritz MA, Howell RJ, Brodsky MB, et al. Moving forward with dysphagia care: implementing strategies during the COVID-19 pandemic and beyond. Dysphagia 2020 Jun 9 [Epub ahead of print].
Namasivayam-MacDonald, A. M., & Riquelme, L. F. (2020). Speech-language pathology management for adults with COVID-19 in the acute hospital setting: Initial recommendations to guide clinical practice. American Journal of Speech-Language Pathology. https://doi.org/10.1044/2020_AJSLP-2000096
Royal College of Speech Language Therapists (RCSLT). Guidance for service delivery, clinical procedures and infection control during COVID-19 pandemic. (link) Accessed Nov 20, 2020.
Soldatova L, Williams C, Postma GN, Falk GW, Mirza N. Virtual Dysphagia Evaluation: Practical Guidelines for Dysphagia Management in the Context of the COVID-19 Pandemic. Otolaryngol Head Neck Surg. 2020 Sep;163(3):455-458. doi: 10.1177/0194599820931791. Epub 2020 May 26. PMID: 32450732.
Speech- Language and Audiology Canada. (2020). COVID-19 update: Speech-language pathology services in health care settings during the COVID_19 pandemic. https://www.sac-oac.ca/news-events/news/speech-language-pathology-services-healthcare-settings-during-covid-19-pandemic
This document was developed by the Swallowing Rehabilitation Research Lab (SRRL). SRRL is guided by the current best available evidence at the time of publication. The application and use of this document is the responsibility of the user. SRRL assumes no liability resulting from any such application or use.