PRIORITISATION

Whos next?
When you work in the acute dysphagia sector and demand for your service outstrips supply, you have to decide who needs to be seen first and who can wait longer without a negative impact on their recovery or condition. Inspired by a previous article about prioritising new referrals, Nicola Allan and Claire Cahoon have developed a two stage tool to support their teams decision making across new referrals and existing clients.
ts a scene no doubt familiar to us all: having to prioritise and fulfil a duty of care to those on our existing caseload, whilst taking into consideration the needs of the patients on the waiting list. This - combined with variable staffing levels, a high workload, and the need to support new graduates who are still developing their decision making skills - can make prioritisation a real challenge. We were inspired to delve deeper into prioritisation by Alison Newton and Linzie Priestnalls article Decision time (2008). Its publication coincided with an exceptionally busy period in our acute department, and we saw huge potential benefits in using such a tool. After contacting the wider speech and language therapy community for further ideas via the Bulletin of the Royal College of Speech & Language Therapists (RCSLT), we realised there were few prioritisation tools already in use, and those that were available did not match the requirements of our department. We therefore wanted to produce our own practical tool, based on RCSLT guidelines (2006), to speed up decision making and ensure objectivity. We also hoped it would be useful for more inexperienced members of staff, and reduce any stress or uncertainty they may feel when prioritising in-patients. READ THIS IF YOU HAVE MORE CLIENTS THAN CLINICAL TIME ARE KEEN TO MAKE FAIR DECISIONS WANT TO OFFER A CONSISTENT SERVICE

Photo (l-r) Nicola Allan, Jenny Pennington, Claire Cahoon, Terri Horton. Terri is head of adult speech and language therapy and Jenny is also a speech and language therapist.

Starting point

We used the Flow chart for new referrals (Newton & Priestnall, 2008) as our starting point and, following positive feedback from colleagues about the concept, produced our first draft. The tool gradually evolved and changed over the next ten months in light of real life prioritisation issues and comments from colleagues. The end result is a two stage Prioritisation Tool for Dysphagia Assessment. Stage 1 is an initial screen, and Stage 2 provides additional important factors to consider if further prioritisation is needed. We envisage the process will be most helpful when the number of patients requiring assessment exceeds the clinical time

available. We felt it was important that the tool could be used as a record of decision making. It therefore contains space for patient information, with a view to it being retained in the patients notes if considered necessary. The tool also reflects our teams requirement for a doctors signature on all dysphagia referrals. This is a local policy which is under frequent review. We feel it has benefits such as encouraging doctors to take an active role in a patients dysphagia management, which is particularly helpful with quality of life decisions. Discussions regarding eating and drinking as part of end of life care are often very challenging and we find that, when doctors have been involved from the point of referral, these discussions are much easier. A recent audit of our swallow screening procedure indicated that the need for a doctors signature did not delay referral time.

For us, the important elements are: The tool is not intended to be prescriptive or to provide all the answers, and cannot take into account all factors that influence clinical decision making. We have therefore incorporated a reference to the need to use clinical judgement when making prioritisation decisions. For example, the date of discharge may influence how quickly a patient is seen, or a patient referred for an urgent videofluroscopy may be considered a priority over some others. We have included consideration of our existing caseload to reflect good practice and duty of care. On trialling a pilot version with the case examples featured in Newton & Priestnall (2008), we realised that too many were evaluated as high priority

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and therefore the usefulness of the tool was diminished. We developed Stage 2 (Additional factors to aid prioritisation) to help with further prioritisation of patients who fall into the high priority category. We also included factors such as distress and end of life issues, as the importance of these when evaluating priorities cannot be overestimated. of prioritisation, we feel it is a useful, practical process, based on professional guidelines, which will speed up and guide what can be a stressful SLTP and challenging aspect of our work. Nicola Allan (email nicky.allan@nhs.net) is principal speech and language therapist and at the time of writing Claire Cahoon was a specialist speech and language therapist with NHS Medway Community Healthcare. Claire is now an advanced specialist at the Royal Hospital for Neurodisability (email ccahoon@rhn.org.uk). Acknowledgements Our thanks to Alison Newton and Linzie Priestnall for inspiring this work and to Alison for providing feedback on the first draft of this article. References Newton, A. & Priestnall, L. (2008) Decision time, Speech and Language Therapy in Practice Spring, pp.E1-E3. Available at: http://www.speechmag.com/content/files/ Spr08SLTiPANewtonLPriestnall.pdf. Royal College of Speech and Language Therapists (2006) Communicating Quality 3. London: RCSLT.

Figure 1 Exercise used for evaluation

Using only this information, place these patients in the order that you would carry out an initial swallow assessment: Joan Complaining of food sticking in throat able to eat small amounts, slowly No difficulties managing fluids Is very anxious about her eating Family are keen for her to be seen by speech and language therapy as soon as possible Fred Lily Admitted yesterday with a broken hip Nursing staff report she is being seen by speech and language therapist in the community but are unsure of recommendations Has IV fluids Nil by mouth Jack COPD (chronic obstructive pulmonary disease) On 60% 02 via facemask Alert Nil by mouth Nursing staff concerned about aspiration No non-oral feeding Mabel End stage dementia Safest consistency / Risk feeding assessment requested Nil by mouth for 3 days No IV fluids as too agitated Calling out for water Parkinsons disease Nil by mouth for 2 days No non oral feeding IV (intravenous) fluids in situ Unable to receive medication

Consistency

For evaluation, we asked two newly qualified members of our team and two experienced clinicians to use the tool to prioritise five hypothetical cases for initial dysphagia assessment (figure 1). The results, whilst only based on a small sample, showed almost complete consistency in prioritisation by the four speech and language therapists. The only minor discrepancy was between the two newly qualified therapists prioritisation of Fred and Mabel, with Therapist C choosing Mabel as number one priority, and Therapist D choosing Fred. This highlights that the tool is not prescriptive and should be used as guidance only, in conjunction with clinical judgement. Clinically we did not feel the discrepancy was significant, as both Fred and Mabel could justifiably be seen as the highest priority. Indeed, on any given day, it is very likely that both Fred and Mabel would be seen for assessment. Interestingly, Therapist C reported that she initially selected Fred as the highest priority, but altered her decision after using Stage 2. In our opinion this further highlights the usefulness and importance of this second stage in helping to refine judgement regarding prioritisation. The final version of our tool is in figure 3. Feedback has been very positive. Colleagues report that it is easy to follow and gives a good overview of factors to take into consideration when prioritising an in-patient caseload. Many colleagues have also commented on the tools usefulness for newly qualified therapists and speech and language therapy students. We now use the tool for daily prioritisation when patient numbers exceed the clinical time available, and also to guide newly qualified therapists in their decision making. While it is by no means the solution to the challenges

REFLECTIONS DO I ENGAGE, DEVELOP AND LEARN TO TRUST MY CLINICAL JUDGEMENT? DO I TAKE SUFFICIENT ACCOUNT OF PSYCHOSOCIAL ISSUES WHEN MAKING PRIORITIES? DO I DRAFT IDEAS AND LET THEM EVOLVE IN PRACTICE BEFORE THEY ARE FULLY IMPLEMENTED?
What difference has this article made to you? Please see the information about Speech & Language Therapy in Practices Critical Friends at www.speechmag.com/About/Friends and let us know.

Critical friends
Alison Newton and Linzie Priestnalls article Decision time inspired Nicola and Claire when they were looking for solutions to prioritisation. That article is available online at www.speechmag.com/Resources/Reprints and includes interesting background on how members of the department were orientated to the task. As part of Speech & Language Therapy in Practices informal peer review process (www.speechmag.com/About/ Friends), Alison agreed to look over Nicola and Claires article. Alison commented: The article is great and the flow chart looks excellent. It looks like Claire and Nicola have capitalised on the parts of our flow chart that would work best for their service and their team. Their flow chart looks smart and is easy to follow. Claire and Nicola have significantly improved upon the 'usability' of the flow chart compared with the one that Linzie and I put together for our prioritisation policy. Thanks for letting me have a look at the article. I have recently taken up a new post as Lecturer at Birmingham City University. I look forward to the publication of this article and teaching my speech and language therapy students about prioritisation. The decision making tasks are going to foster some interesting discussions!

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Figure 2 Prioritisation for Dysphagia Assessment Patient Name NHS No. Date of birth Date Name of staff member spoken to Ward Speech and language therapist Medical diagnosis/reason for admission

STAGE 1 - Initial prioritisation screen (Remember that professional duty of care exists for patients on existing caseload) Existing caseload

New referral received

Check screening test and referral card completed (must be signed by doctor)

Phone review or indirect review

Has the patient passed the alertness screen? YES Is the patient able to receive essential medication? YES Is the patient nil by mouth? * NO Is there a concern about aspiration? NO LOWER PRIORITY

NO

Unable to assess phone in 24 hours

If concerns raised...

If no concerns raised...

NO

HIGH PRIORITY NO

YES

Does the patient have non-oral feeding? YES

YES

HIGH PRIORITY LOWER PRIORITY

*If nil by mouth for more than 3 days contact dietitians in line with local agreement between speech and language therapy and dietetic teams

STAGE 2 - Additional factors to aid prioritisation Length of time nil by mouth Distress expressed by patient / carer Ability to receive IV fluids / meds - yes / no Respiratory status Any current swallow recommendations from community? Has a safest and most comfortable consistencies whilst accepting high risk of aspiration assessment been requested? Other PLEASE NOTE: CLINICAL JUDGEMENT MUST ALWAYS BE USED WHEN MAKING PRIORITISATION DECISIONS

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