Speech-Language Pathology Management for Adults with COVID-19 in the Acute Hospital Setting: What Do We Know?
Luis F. Riquelme 1,2,†,*, Sara Diab 3, Angela Horyacheva 3, Isabel Huribal 1, Andreea Shellerud 1, Sophia Werden Abrams 3, Ashwini M. Namasivayam-MacDonald 3,†
Speech-Language Pathology, New York Medical College, 40 Sunshine Cottage Rd, Valhalla, NY 10595, United States
Maimonides Health, 4802 Tenth Avenue, Brooklyn, NY, 11219, United States
School of Rehabilitation Science, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
† These authors contributed equally to this work.
* Correspondence: Luis F. Riquelme
Academic Editor: Gerhard Litscher
Special Issue: Swallowing Rehabilitation and Management in Older Adults
Received: April 29, 2022 | Accepted: August 08, 2022 | Published: August 11, 2022
OBM Integrative and Complementary Medicine 2022, Volume 7, Issue 3, doi:10.21926/obm.icm.2203036
Recommended citation: Riquelme LF, Diab S, Horyacheva A, Huribal I, Shellerud A, Abrams SW, Namasivayam-MacDonald AM. Speech-Language Pathology Management for Adults with COVID-19 in the Acute Hospital Setting: What Do We Know?. OBM Integrative and Complementary Medicine 2022; 7(3): 036; doi:10.21926/obm.icm.2203036.
© 2022 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.
The purpose of this study was to collate and summarize the content covered in published literature describing speech-language pathology management of adult patients with COVID-19 in the acute hospital setting as of February 2022. This review serves as an updated review of the initial recommendations to guide speech-language pathology management for adults with COVID-19 in the acute hospital setting previously provided by Namasivayam-MacDonald and Riquelme in July of 2020. This scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Scoping Review Extension protocol. We searched for relevant peer-reviewed articles in the following electronic databases: MEDLINE, EMBASE, and CINAHL. The article review process was conducted using Covidence. Our searches yielded a combined total of 3019 unique citations, of which 54 were accepted for full-text review. Thirty-seven of the 54 studies were review articles, recommendations, or opinion pieces. This translates to mostly low levels of evidence (i.e., Levels VI and VII) and a grade of ‘D’ when applying the American Society of Plastic Surgeons grade recommendation scale for evidence-based clinical practice guidelines, meaning there is little or no systematic empirical evidence available. The remaining 17 provided empirical data, which translates to higher levels of evidence and a grade of ‘B’. The empirical data shared in this scoping review provide support for the ongoing role of the SLP in the acute care setting and the impact COVID-19 and its variants have on the underlying systems for communication and swallowing. This document serves as further proof of the need for ongoing research into the clinical presentations of patients with speech-language, cognitive and/or swallowing deficits resulting from COVID-19, as well as into systems of care that will provide the best outcomes in their rehabilitation.
COVID-19; acute care; speech-language pathology; rehabilitation
Coronavirus disease (COVID-19) emerged as a global pandemic after an isolated infection of an unknown nature was identified in December 2019. In the weeks that followed, a new beta coronavirus strain called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was determined to be the causative agent for this unprecedented infectious disease. For over two years the COVID-19 pandemic has devastated the lives of millions of people around the world. At the same time, its negative impacts on the global economy and health care system have been unfathomable and are still ongoing . To date, evidence suggests that human-to-human transmission of COVID-19 occurs through contact with respiratory droplets generated by coughing and sneezing, infected secretions (such as saliva and sputum), and contaminated surfaces . Most recently, it has been learned that the risk of infection through contact with contaminated surfaces or objects is generally considered to be low . Since December 2020, several variants have been identified and assigned Greek letter designations by the World Health Organization (WHO). According to the National Institutes of Health (NIH) COVID-19 Treatment Guidelines webpage , “the data on the emergence, spread and clinical relevance of these new variants is rapidly evolving; this is especially true for research on how variants might affect transmission rates, disease progression, vaccine development, and the efficacy of current therapeutics.”
As new variants have emerged throughout the pandemic, speech-language pathologists (SLPs) have continued to perform clinical procedures that involve contact with the mucous membranes of the upper airway, as well as exposure to body fluids, such as saliva and respiratory droplets. In addition to direct clinical examinations, clinicians in many settings have returned to performing instrumental examinations and providing treatment/management services on a regular basis. The use of personal protective equipment (PPE) during speech-language pathology clinical care has varied by facility, setting and by procedure across the globe. Modifications in PPE are often dictated by setting, level of care, and in some instances, by vaccination status of the person being examined or treated. The impact of the pandemic on the clinical practice of SLPs worldwide remains to be further studied. Many colleagues report high variability in volume and caseload mix. According to Kearney et al. , a survey of 665 clinicians from the United States and Canada revealed that completing endoscopic procedures was reduced in volume from 39% to 3% due to the pandemic. Similarly, frequency of tracheoesophageal puncture prosthesis changes was reduced from 24% to 6%. The authors also reported that “COVID-19 testing rates of SLPs, the percentage of SLPs experiencing the financial impact of the pandemic, and percentage who were furloughed varied across SLP work setting.” As new variants emerge and case counts increase and then slowly decrease again, SLPs are likely to continue experiencing hardships.
Given the many changes and barriers to practice experienced by SLPs beginning in March 2020, initial recommendations to guide SLPs’ clinical care for patients with COVID-19 were developed by Namasivayam-MacDonald and Riquelme  early in the pandemic. These recommendations were informed by similar recommendations developed for physical therapists and were subsequently adapted with the help of clinicians involved in dysphagia practice from around the globe. The purpose of these initial recommendations was to guide clinical practice based on what was known about COVID-19 at the time of publication. Unfortunately, there were few research studies available to inform or support the recommendations. As such, the purpose of the current study was to collate and summarize the content covered in published literature describing speech-language pathology management of adult patients with COVID-19 in the acute hospital setting. At present, given the multiple variants that have emerged, the clinical picture of patients with COVID-19 and the impact on the acute care setting has varied when compared to the initial wave. It is also relevant to note that the prognosis for patients with COVID-19 in the rehabilitation and ambulatory settings remains minimally explored to date. This review is to serve as an updated review of the recommendations previously provided by Namasivayam-MacDonald and Riquelme  for speech-language pathology management of adult patients with COVID-19 in the acute hospital setting.
2. Materials and Methods
This scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Scoping Review Extension protocol  and was not a candidate for institutional ethical review. An original search was conducted in February of 2022. We searched for relevant peer-reviewed articles in the following electronic databases: MEDLINE, EMBASE, and CINAHL. The general search strategy, formulated by all authors in conjunction with a librarian, can be found in Table 1, and included terms related to COVID-19, speech-language pathology practice, and duties within an acute care setting and related to pandemic protocols. Google Scholar was also searched to find grey literature using the same search terms. E-publications that were not yet indexed and thus did not appear in our search results, were not included in this review.
Table 1 Electronic search strategy.
Of note, the initial recommendations provided by Namasivayam-MacDonald and Riquelme  were based on international consensus and guidelines initially developed by and for physical therapists. The SLP-specific recommendations  did not involve a review of the literature given that the recommendations were developed only two months into the COVID-19 pandemic when no COVID-related empirical evidence was available related to SLP practice. As such, the search strategy employed within the current study serves as an attempt to systematically gather the literature and data that has since been published.
2.1 Study Selection
The article review process was conducted using Covidence (www.covidence.org). Five independent raters excluded citations if they had no abstract; were conference proceedings; did not discuss COVID-19; there was no mention of speech-language pathology or related titles used globally (e.g., speech-language therapist, phonoaudiologist, logopede); there was no mention of practice in an acute care hospital setting; and adult patients were not included/discussed. All articles at both the title and abstract screening stage and the full-text review stage underwent duplicate review and discrepancies were resolved by consensus with a third reviewer. The kappa coefficient was calculated to determine interrater reliability at both the abstract and full article review phase.
2.2 Data Extraction
Data were extracted descriptively by a single reviewer and were cross-checked for accuracy by a second rater. Data extraction included: author; year of publication; country of publication; type of study; purpose; setting; members of the care team; PPE used; number of patients diagnosed with COVID; average age of patients diagnosed with COVID; severity of COVID; and main conclusions. Level of evidence was also assigned to each included article based on a nursing care guidelines , where Level I is the highest level of evidence and involves systematic reviews of meta-analyses of relevant randomized-controlled trials (RCTs) or evidence-based clinical practice guidelines based on systematic reviews of RCTs, and Level VII is the lowest level of evidence because the evidence comes from the opinion of authorities and/or reports of expert committees.
In addition to this information, reviewers also mapped each article to the initial recommendations outlined by Namasivayam-MacDonald and Riquelme  for speech-language pathology management of adult patients with COVID-19 in the acute hospital setting. These open access guidelines published by the American Journal of Speech-Language Pathology were developed based on the physiotherapy guidelines for COVID-19 . The SLP recommendations were extremely comprehensive and covered five main topic areas: 1) workforce planning and preparation recommendations [18 recommendations]; 2) initial SLP involvement with patients with COVID-19 and patients under investigation [13 recommendations]; 3) active SLP involvement with patients with COVID-19 and patients under investigation [11 recommendations]; 4) transmission-based precautions [appropriate use for 5 categories of PPE]; and 5) augmentative and alternative communication (AAC) options for patients with COVID-19 and patients under investigation in isolation [possible solutions for 11 different patient needs]. The workforce planning recommendations include planning for increases in the required SLP workforce, and identifying staff who had the skills to work in the intensive care unit, as well as how to build capacity if intensive care unit experience is lacking. The recommendations discussing initial SLP involvement with patients with COVID-19 included points about when to conduct assessments, how to reduce exposure, and assessment options in the absence of adequate PPE. Active SLP involvement recommendations focused on caseload management, service delivery and documentation. More specifically, the recommendations focused on patients that presented with various issues associated with dysphagia, such as respiratory compromise, decompensation, cognitive difficulties, and mechanical ventilation. For the latter two topics, appropriate use of PPE and AAC options, specific recommendations were provided based on type of PPE or patient need, respectively, rather than a numbered list of more general recommendations. As such, given that specific, numbered, recommendations were provided for each of the first three topic areas, the articles included in the current review were mapped to these specific recommendations. For the recommendations pertaining to PPE and AAC, reviewers indicated whether these topics were covered in the articles included within the current review due to the lack of specific, numbered recommendations.
A PRISMA flowchart depicted in Figure 1 reflects the search and review process for the current review. Our searches yielded a combined total of 3019 unique citations, of which 54 were accepted for full-text review. At the title and abstract review stage, the kappa coefficient was 0.81 and at the full article review stage the kappa coefficient was 0.90.
Figure 1 PRISMA diagram.
As can be seen in Table 2, 17 out of the 54 publications provided empirical data [5,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25]. Most evidence was either Level IV (well-designed case-control or cohort studies) or VI (case study) and a grade of ‘B’ when applying the American Society of Plastic Surgeons grade recommendation scale for evidence-based clinical practice guidelines , meaning that empirical evidence is available and findings are consistent, but clinicians should remain alert to new information and patient preferences. In Table 3 the 37 publications that did not include empirical data (i.e., review articles, recommendations, or opinion pieces) can be found [6,11,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62]. This translates to mostly low levels of evidence (i.e., Levels VI and VII) and a grade of ‘D’ when applying the American Society of Plastic Surgeons grade recommendation scale for evidence-based clinical practice guidelines , meaning there is little or no systematic empirical evidence available. As such, it is recommended that clinicians should consider all options in their decision making and be alert to new published evidence.
Table 2 Overview of the articles with empirical data included in the study according to type of article, level of evidence and country/region of origin. Levels of evidence rating scheme is based on the evidence-based nursing care guidelines , where Level I is the highest level of evidence and Level VII is the lowest level of evidence.
Table 3 Overview of the articles that lacked empirical data (e.g., reviews, recommendations, opinions, etc.) included in the study according to type of article, level of evidence and country/region of origin. Levels of evidence rating scheme is based on the evidence-based nursing care guidelines , where Level I is the highest level of evidence and Level VII is the lowest level of evidence.
Table 4 displays the information covered in each of the included publications that contained empirical data, per the recommendations developed by Namasivayam-MacDonald and Riquelme  pertaining to SLP practice in acute care during the COVID-19 pandemic. This mapping allows us to determine the information that can be gathered from each article, as it pertains to workforce planning, SLP assessment and treatment, PPE requirements and use of AAC. Publications that did not include empirical data were excluded from this table, as low level evidence should not be used to support recommendations made by Namasivayam-MacDonald and Riquelme .
Table 4 Publications included in the review that contained empirical data mapped to workforce planning recommendations covered by Namasivayam-MacDonald and Riquelme  in their initial recommendations to guide clinical SLP practice when working with adults with COVID-19 in the acute care setting.
Twenty-two out of 54 (41%) articles included in this review discussed workforce planning [5,12,13,14,23,31,32,34,35,40,41,42,44,45,47,52,54,56,57,58,60,63]. However, as can be ascertained from Table 4, only 5 out of 17 (29%) studies with empirical data [5,12,13,14,23] supported the recommendations initially developed by Namasivayam-MacDonald and Riquelme . Notably, pandemic planning was the focus of the recommendations paper by Wong , but this was based on a business model rather than empirical evidence. Across all types of publications, the most commonly covered topics surrounding workforce planning included compliance with relevant national, provincial/state/territorial, and/or hospital guidelines for infection prevention and control (recommendation 1.12; [5,23,31,54,60,63]); recognition that staff have an increased and/or varied workload with a heightened risk of anxiety both at work and at home (recommendation 1.17; [32,34,40,58]); and considerations around debriefing and psychological support for staff (recommendation 1.18; [32,34,40,58]). Of note, the article by Mumtaz and colleagues  focused on the fears of healthcare workers associated with COVID-19 contraction. Per Table 4, recommendations specifically supported by empirical evidence were recommendations 1.4, 1.6, 1.7, 1.10, and 1.12. Recommendations not covered by any publications in the review pertaining to workforce planning included: taking advantage of the skills of SLPs with ICU experience (recommendation 1.5); considering staff who are at high risk of contracting the virus when planning staffing and rosters (recommendation 1.8); considerations for staff who are pregnant (recommendation 1.9); and determining facility plans for cohorting COVID-19 patients and using these plans to determine resource requirements (recommendation 1.14).
Initial SLP involvement with patients (i.e., screening and assessment) was the most commonly covered topic in the literature, discussed by 41 out of 54 (76%) articles [5,10,11,15,16,17,18,20,22,23,24,25,27,28,29,30,31,32,33,36,37,38,40,43,44,45,47,48,49,50,51,52,53,54,57,58,59,60,61,62] . However, as can be ascertained from Table 5, 12 out of 17 (71%) articles with empirical data [5,10,11,15,16,17,19,20,22,23,24,25] supported the initial involvement recommendations developed by Namasivayam-MacDonald and Riquelme . Across all articles, the most commonly discussed topic was administration of endoscopic procedures (recommendation 2.10; [5,15,16,20,23,25,28,30,31,33,36,38,44,47,51,52,53,54,57,58,59,61,62,63]). Other commonly discussed topics included: performing point-of-care risk assessments to determine needs for videofluoroscopic swallowing studies (recommendation 2.9; [28,30,33,36,38,47,50,51,53,54,57,58,63]); the implementation of face-to-face procedures only when required (recommendation 2.1; [18,28,29,37,40,47,51,52,54,58,59,63]); being mindful of the length of close contact with patients with COVID-19 (recommendation 2.5; [25,27,28,29,36,38,40,44,45,47,48,50,51,54,58,59,61,62]); and avoiding testing volitional cough and gag reflex (recommendation 2.6; [16,23,28,31,33,36,45,47,48,50,51,54,57,58,62]). Per Table 5, recommendations specifically supported by empirical evidence were recommendations 2.1, 2.3, 2.5, 2.6, 2.7, 2.8, 2.10 and 2.11. None of the articles included in this review discussed documenting modifications to clinical procedures (recommendation 2.13) and only two highlighted the differences in assessment of patients with COVID-19 in versus outside of the ICU (recommendation 2.4; [47,49]).
Table 5 Publications included in the review that contained empirical data mapped to initial involvement recommendations for practice with patients with COVID-19 covered by Namasivayam-MacDonald and Riquelme  in their initial recommendations to guide clinical SLP practice when working with adults with COVID-19 in the acute care setting.
Active SLP involvement (i.e., management of communication and swallowing difficulties) was also commonly covered by all articles included in the review, with the only topics not being covered being end-of-life care for patients with COVID-19 (recommendation 3.8) and the documentation of modifications to clinical procedures (recommendation 3.11). As can be ascertained from Table 6, 12 out of 17 (71%) articles with empirical data [5,10,11,14,15,18,20,21,22,23,24,25] supported the active SLP involvement recommendations initially put forth by Namasivayam-MacDonald and Riquelme . These articles supported recommendations 3.1, 3.2, 3.3, 3.4, 3.6, 3.7, 3.9, and 3.10.
Table 6 Publications included in the review that contained empirical data mapped to active SLP involvement recommendations for practice with patients with COVID-19 covered by Namasivayam-MacDonald and Riquelme  in their initial recommendations to guide clinical SLP practice when working with adults with COVID-19 in the acute care setting.
PPE recommendations were provided in almost one third (17 out of 54; 31%) of all publications [28,29,31,32,33,40,46,51,53,54,56,57,58,61,62,64], but PPE was not explicitly discussed with supporting evidence in any of the articles reporting empirical data. Suggestions for integration of AAC devices, whether they be low or high technology, were only discussed in five publications [27,31,32,41,58], but none with empirical data.
The COVID-19 pandemic has been a global fixture for over 24 months now. This is a relatively short time for extensive empirical data specific to the practice of SLPs in acute care settings to emerge in peer-reviewed journals. Only 17 of 54 studies included in this review provided empirical data (see Table 2). This is a small amount of support to guide the broad areas of SLP practice engaged in the acute care setting. The remaining 37 studies encompass reviews, recommendations, or opinion studies (see Table 3).
As we focus on the available empirical data to date, Table 4, Table 5 and Table 6 provide a listing of the publications within the framework espoused by Namasivayam-MacDonald and Riquelme . In the area of workforce planning (Table 4), the important role played by SLPs with this population is presented by Bellinger, Ouellette & Leonard Robertson . They reported on the effectiveness of physical therapy, occupational therapy, and speech-language pathology services to patients with moderate to severe COVID-19 in an inpatient rehabilitation unit. They analyzed pre- and post-testing results and found statistically significant improvements in mobility, self-care, and cognitive performance. The authors concluded that the data presented “can be used to impact the appropriate progression of patients through the health care continuum”, further demonstrating the important role of the interdisciplinary team with this population.
In a retrospective review of 164 COVID-19 patients referred for speech-language/swallowing assessment, Archer and colleagues  reported that 78% had undergone a tracheotomy and 13.4% presented with a new neurological impairment. While individualized compensatory approaches were utilized for dysphagia management, only 11% were found to be candidates for direct exercise programs. At their hospital in the UK, the authors reported that patients were introduced to some form of oral intake by day #2 post-initial assessment. In their sample, all patients were discharged from the hospital on oral diets. Post-discharge, 17.1% presented with dysphonia and 7.8% with dysphagia, requiring community-based follow-up. This data suggests that while clinical improvements may differ from other clinical populations, the need for follow-up services post discharge from hospital needs further attention. This data supports the need to identify existing resources for service provision as well as SLP training.
Attempts to further characterize the changes in oropharyngeal and laryngeal physiology have also been noted. Sandblom and colleagues  evaluated 25 COVID-19 patients in the ICU in the latter stage of care or shortly post-discharge. Upon endoscopic evaluation, they found pooling of secretions in 92% of patients and 44% showed signs of silent aspiration on at least one bolus trial. All patients showed post-swallow residue in the pharyngeal recesses. Additionally, Sandblom and colleagues noted that 76% of their sample presented with impaired vocal fold movement and erythema of the vocal folds (60%) and of the arytenoid region (60%). It is unclear how long the impairments persisted in the sample; however, it becomes immediately clear that SLP intervention is critical for rehabilitation of both swallowing and voice disorders in this population.
Recommendations for practice by SLPs with this population (initial and active) are presented in Table 5 and Table 6. Published clinical reports suggest that patients with COVID-19 also present with dysphagia and dysphonia post-extubation secondary to acute respiratory distress syndrome (ARDS) [10,19]. Severe dysphagia persisting 24 hours post-extubation was reported in 20% of patients by Lima et al. , requiring full or partial enteral tube feeding, and 53% presented with moderate dysphagia requiring dietary or behavioral interventions. Dysphagia has previously been associated with ARDS and correlated with length of stay in the ICU in patients without COVID-19, persisting beyond hospital discharge in one-third of patients .
In efforts to better understand the impact of the pandemic on SLPs in the acute care setting in South Africa, Adams and colleagues  shared insightful information on the changes in SLPs roles, limitations in services provided to patients (e.g, no ambulatory services) and the overall resilience of healthcare professionals facing novel and unprecedented situations. While written from the perspective of SLP practice in South Africa, the insights shared are likely common for countries where access to allied health professionals is limited.
Despite this evidence demonstrating the need for speech-language pathology services with this complex patient population, the mechanisms leading to speech, language, cognition, and swallowing difficulties in this population are largely hypothesized. A case study by Cavalagli and colleagues  outlines the potential neurological pathophysiology of cranial nerve dysfunction that results in dysphagia. Figure 2 of their article provides a conceptual model of the patient’s possible pathogenic correlation, noting that in conjunction with ICU acquired weakness, patients present with neuromuscular incoordination leading to poor respiratory swallow coordination, and impaired management of oropharyngeal secretions. In efforts to better understand the complexity of mechanisms that lead to communication and swallowing symptoms in this population, a review of clinical presentations was included in Figure 2 of the study by Cavalagli and colleagues to facilitate our evolving understanding of the pathophysiology involved.
Specific to voice sequalae, another set of recommendations was published by a group of 11 experts in voice and swallowing from five different countries . This group reached a 95% consensus for the 65 recommendations presented to clinicians on the management of voice disorders during the pandemic. More recently, Boggiano and colleagues  studied 25 patients retrospectively who had undergone trans-laryngeal intubation during the course of their treatment for COVID-19. Their results showed that 63% of the sample presented with laryngeal abnormalities that were considered significant. These included edema, abnormal vocal fold movement, atypical lesions, and erythema. In addition, the authors report that 88% of patients who aspirated during the endoscopic examination did so silently. Overall, Boggiano et al.  conclude that “the incidence of laryngeal pathology in this sample was higher than a non-COVID-19 cohort with similar characteristics.”
When addressing the needs of patients with a tracheoesophageal voice prosthesis, Goldstein et al.  suggest increased use of a heat moisture exchanger (HME) to reduce risk of transmission, reduce crusting and reduce potential trips to the hospital. This recommendation was based on their review of the literature. Proposed guidelines for protection during tracheotomies or care for open tracheostomies are presented in a review paper by Jacob et al. . They suggest creating a core COVID-19 Airway team that will adhere to strict protocols and reduce the risk of transmission among other colleagues. In a prospective study, Rouhani et al.  reported on the high incidence of laryngeal injury among patients who underwent endotracheal entubation and tracheostomy insertion during the COVID-19 pandemic. The study is ongoing as the team of researchers aim to “study complications over the medium term, which may offer insight into the natural history of ICU related laryngeal injury.” This would be a good addition to future empirical evidence.
The empirical studies identified provide support in a range of practice areas. Dawson et al.  presents compelling evidence from one hospital in Birmigham, UK on the prevalence of dysphagia in patients with COVID-19 based on experience from the first wave of the pandemic. A noted in Table 4 and Table 5, this supports initial and active SLP involvement for patients with COVID-19. Specifically, they found 29.9% of patients admitted with SARS-CoV-2 were referred for swallow assessment. Their findings suggest (p. 986):
- The prevalence of dysphagia is high in patients admitted with COVID-19, which is an important facet of rehabilitation needs.
- Dysphagia was multi-factorial, and co-existed with delirium, fatigue and difficulty achieving effective respiratory-swallow coordination.
- Patients with a tracheostomy following COVID-19 required greater total therapy sessions from the speech-language pathologist.
- Acute care protocols require robust, well-established and appropriately funded SLP teams to provide timely, effective rehabilitation for patients with complex upper airway compromise following COVID-19 and acute care admission.
- A whole systems approach from an integrated multi-disciplinary team is required to manage concurrent and complex etiologies associated with COVID-19 and an acute care admission.
- With intensive therapy, most patients can regain normal swallow function following COVID-19.
In a study conducted in the Republic of Ireland, Regan and colleagues  reported that post-extubation, 90% of patients referred for a dysphagia assessment required altered oral intake, 36% were not allowed oral intake and 59% required tube feeding. In their analysis, age, proning and pre-existing respiratory disease were predictors of oral intake status post-extubation. In their sample, 66% presented with dysphonia. At time of discharge, dysphagia persisted in 27% of the participants and dysphonia in 37%. Based on their data, they conclude that “Prompt evaluation and intervention is needed to minimize complications and inform rehabilitation planning.”
One of the few treatment papers found for this review was a case study where pharyngeal electrical stimulation was utilized to improve oropharyngeal dysphagia . The data suggests that dysphagia intervention is crucial to optimize full recovery in this population. In the category of transmission-based precautions, the focus on telehealth in acute care has been mentioned but not necessarily completely studied. While a review, the paper by Curtz and colleagues  presents several algorithms for physical therapy, occupational therapy and speech-language pathology decision-making. The flow charts are comprehensive and focus on identifying appropriate patients for telehealth intervention while in the acute care setting.
Overall, the empirical data included provides support and some guidance to the SLP working in the acute care setting. Areas that remain to be explored are specific clinical service protocols that demonstrate positive outcomes. For example, has the manner in which a clinical swallow assessment is conducted changed due to what we have learned from our work with patients with COVID? Anecdotal clinical reports suggest that some clinicians remain conservative in their approach, while others took risks during the pandemic and have now incorporated models of care that may be seen as more aggressive. The data on these changes, presented as an example here, are yet to be shared.
It is of interest to note that in a literature and international guidelines review article focused on dysphagia in patients with COVID-19 published in November 2020 , Vergara and a group of international co-authors identified and reported on three publications that met inclusion criteria, as well as 19 international guidelines. In their conclusions they state: “International associations have provided extensive guidance regarding the level of risk related to the management of dysphagia in this population. To date, there are no scientific papers offering disease and/or recovery profiling for patients with dysphagia and coronavirus disease 2019.” Given the few studies found at the time of their review, the current mapping review serves as a more detailed follow-up, demonstrating that primary data collection has been conducted and analyses are ongoing to deepen our understanding of how SLPs can effectively manage those with COVID-19.
In looking at how to best prepare for future incoming waves of this or other pandemics that impact SLP practice in hospital settings, Wong  presents an interesting view on pandemic planning for speech-language pathologists. She highlights the “lack of speech-language pathology-specific publications on frameworks to guide pandemic planning.” The analysis presented was conducted using the Stuff, Staff, Space and Systems framework  and includes a comprehensive table of suggestions for the clinician (p. 157). Collaboration, supports and review of systems are highlighted throughout. The systems approach presented serves to proactively assess potential problems before they arise and to help plan for future events. Wong  highlights the need to create a “culture of learning” and likens the process of preparation to that of a clinical assessment, where “understanding the system in which the speech-language pathology service works may be more thoroughly and efficiently tackled through a well thought out assessment.” The information presented and the framework used should be kept in mind for future healthcare crises where resources are stretched.
As we move forward, interesting gaps and questions are raised by Coutts  regarding dysphagia services to this clinical population and the essential nature of speech-language pathology services. Several of the gaps presented include the limited data on prevalence of dysphagia countries outside of North America and Europe, the impact of this pandemic on under-resourced healthcare systems, the unclear future of the impact COVID-19 will have on the profession, and the paucity of global data on dysphagia practice in different facilities. The author emphasizes that SLPs need to advocate for their roles in high care settings and that telerehabilitation warrants further investigation.
This scoping review of the literature, based on the initial, open access recommendations set forth by Namasivayam-MacDonald and Riquelme  highlights the need for, and benefits of, the ongoing investigation of how speech-language pathology service delivery models and specific clinical protocols were, and continue to be, challenged during this pandemic and its ongoing waves. The incoming myriad of patient presentations further challenge investigations into specific patient care approaches. In particular, the emergence of new and heterogenous variants in combination with individual vaccination status and comorbidities. It is highly suggested that the decision-making process clinicians undergo when providing communication and dysphagia services in the acute care setting to adults be further explored and shared, within the context of variants and overall sequalae. It is relevant to note that much of the empirical data available to date relates to the initial wave of the pandemic, hence the integration of findings with current trends must be prioritized by clinicians worldwide. The underlying neurophysiology impacted by COVID-19 also warrants exploration in the context of communication, cognition, and swallowing. Furthermore, it is important to recognize the changing rehabilitation needs and the impact of long COVID on this population moving forward. Long COVID presents challenges to many in their daily lives and little is known about its impact on patient care upon re-admission to the acute care setting, for related or unrelated causes. The profession of SLP and future practice has been impacted and will continue to be influenced by the ongoing exploration on how we do what we do.
In conclusion, SLPs remain essential healthcare workers at the frontlines. The empirical data shared in this scoping review provides support for the ongoing role of the SLP in the acute care setting and the impact COVID-19 and its variants have on the underlying systems for communication and swallowing. The non-empirical data presented and available to date allow for additional exploration of the role of the speech-language pathologist with this specific clinical population. The recommendations previously provided by Namasivayam-MacDonald and Riquelme  have been explored and updated from the available evidence. This document serves as proof of the need for ongoing research into the clinical presentations of patients with speech-language, cognitive and/or swallowing deficits resulting from COVID-19, as well as into systems of care that will provide the best outcomes in their rehabilitation.
LFR: Conceptualization, methodology, supervision, writing. SD: Methodology, data curation. AH: Methodology, data curation. IH: Methodology, data curation. AS: Methodology, data curation. SWA: Methodology, data curation. ANM: Conceptualization, methodology, formal analysis, supervision, writing.
The authors have declared that no competing interests exist.
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