5 Things You Need to Know About Working in the Neonatal Intensive Care Unit

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If you answered yes to any of the questions in my first post about wanting to work with acute care infants, then read this follow-up!

  1. The NICU is an intensive care unit: Infants in the NICU are critically ill or were in the recent past. These most fragile patients can become physiologically unstable at any time—and it might happen during your therapy. The emotional roller coaster of NICU leaves families fragile, too.
  2. It’s not easy to practice in the NICU environment: Quick and constant losses and triumphs cause emotions to run high. An infant’s status can change at any time. Caregivers are highly skilled and passionate, which sometimes leads to strong opinions and respectful disagreements. The SLP needs to thoughtfully collaborate, yet at times take a stand.
  3. The NICU SLP requires advanced practice skills: It’s not just knowing what to do, but what not to do. We often support feeding/swallowing, so the risk for compromising an infant’s airway is significant. Essential skills include solid critical reflective thinking, the ability to complete a differential, and broad, multi-system knowledge about preterm development and swallowing/feeding. Your preparation should include solid experience with the birth-to-3 patients, as well as continuing education, mentorship and guided participation with many infants in both the newborn nursery and the NICU. The NICU is too demanding to be an initial independent placement after graduate school.
  4. The NICU evidence base is rapidly evolving: Read, read, read as much professional neonatal literature as possible. Sources are not just within our field but also in medical, nursing and OT/PT journals. Our role is not only to understand the evidence base, but to bring it to the NICU team. Neonatologists and neonatal nurses will ask “why?” and we must be able to discuss the research-based evidence along with our clinical wisdom: For example, if you recommend changing from “volume-driven” to “infant-guided” feeding.
  5. The NICU is rewarding: After almost 30 years working full time in the NICU, not a day goes by that I don’t learn something, make a difference in an infant’s life or experience the joy of a grateful “thank you!” from a family. The appreciation from nurses and neonatologists when an infant can now feed safely and, therefore, go home, makes your day. With such rewards, however, comes great responsibility. In our hands lies the potential to influence parent-infant relationships through positive neuro-protective feeding experiences that wire the brain toward feeding and build future connections.

If you are thinking about moving into NICU practice, you will find lots of information on my website. Stay tuned for more tips to guide your journey!

 

Catherine S. Shaker, MS, CCC-SLP, BCS-S, works in acute care/inpatient pediatrics at Florida Hospital for Children in Orlando. She specializes in NICU services and has published in this practice area. She offers seminars on a variety of neonatal/pediatric swallowing/feeding topics across the country. Follow her at www.Shaker4SwallowingandFeeding.com or email her at pediatricseminars@gmail.com.

 

Collaboration Corner: Surviving Dysphagia in Schools

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(photo credit)

According to ASHA (2006), 1 in 10 public school speech-language pathologists have a student with dysphagia. I have to be honest; this is a struggle for me. Here’s why: while I have extensive dysphagia experience in medical and private home-based settings, I have difficulty defining my role as an SLP who provides dysphagia therapy in school.

Identifying the obstacles

ASHA has a fairly clear document describing the role of the school-based SLP in schools. However, the perceived obstacles can be daunting (Miller, 2008). The top 4 obstacles consistently come across are: Scheduling and environment, training staff, keeping the lines of communication open between family, staff and outside therapists, and getting student buy-in.

Removing the obstacles

Miller (2008) urges collaboration in treating students with dysphagia. I have the good fortune to work with many talented special educators, nurses, behavior specialists. While I bring the knowledge of dysphagia to the table (bad pun), recognizing the daily demands upon the child requires team-based attention. The following strategies may help balance your student’s dysphagia issues within the context of the school day:

Examine/modify the child’s schedule. Students have very little time to eat. Snack is usually 15 minutes (if at all) and lunch is about the same with recess either before or after. This means students risk missing academic time, social time, recess. Suddenly speech is the no fun allowed zone; staff/students become worried that therapy cuts into these activities.

To help with this let the child start eating in the cafeteria before everyone else arrives, use calming strategies such as music with headphones, or a favorite book for the child to read while he/she is eating. Bring a lunch buddy if it helps. Gradually set limits around how much music she/he can listen to. If a child is too overstimulated during lunch time (elementary cafeterias are quite an experience), have the student eat early and let them read a book or chat with friends. This allows mealtimes to be associated with positive feelings.

Training staff. Many students have a paraprofessional, who also needs to eat their lunch, but guess when their student may need the most support? During lunch, of course. Keep clear instructions and provide hands-on training for staff, give a copy to the school nurse. If there is a change in staffing, make sure the change is with a familiar person who also has training. I have staff sit in on times that are not during their break or lunch. I also encourage the student’s paraprofessional to eat with the student as to “normalize” the experience and to provide role-modeling around food. We have Fun Friday where everyone eats together and we do a fun food play activity. Again, create positive associations with eating (for staff and students!). Staff need consistent access to strategies that will keep the student calm, like this cue card, created by my colleague and co-author of The Behavior Code:

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Communicate closely with families. Eating is a cultural and emotional experience. Ongoing communication with family members provides insight as to when everyone is ready to move to the next step. Clearly communicate that safety is the most important factor in the decisions related to their child’s eating. Encourage parents to come in, or take pictures and video. Use a home-communication journal so notes can go between school and home, highlighting what they ate, how much they ate, and any events that may have affected their eating.

Communicating with outside SLPs. OK, so here’s the deal. Expertise exists across settings. If I don’t do VFSS  on a daily basis, I recognize that I am not an expert in that assessment tool. But if I have a background in dysphagia, have worked in schools for 11 years, have seen this student 3 times a week in their school setting for three years, guess what? I have expertise as well. I can (and should) make a referral for a VFSS by an SLP who has the skill and equipment. Likewise, private SLPs should confer with the school-based SLPs perspectives on eating. Speech-language pathologists need to reach out to one another and value these differences. These differences are a good thing (stepping off of my soapbox now….).

Make the child a part of the process. Keep it low pressure, and rewarding. Take picture of their successes and make a book about it together.  Have them review the book before they eat, so they remember their successes and eating strategies. Here’s a rather crude (but effective) example of a page I wrote with my student:

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Last but not least, set aside your own assumptions of what tastes/feels/smells good….these kids experience food much differently than you do. Remember, eating involves developing trust; it is not a forced process. The end goal is to make eating pleasurable and safe so that mealtime becomes enjoyable for everyone.

Dr. Kerry Davis is a city-wide speech-language pathologist in the Boston area. Her areas of interest include working with children with multiple disabilities, inclusion in education and professional development. The views on this blog are my own and do not represent those of my employer. Dr. Davis can be followed on Twitter at @DrKDavisslp.

Using Your iPad in Dysphagia Therapy

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Photo by rahego

So many people are using iPads, iPhones and iPods in therapy. While there are many other devices out there, I’m focusing on the “iDevices” because those are the devices that I know the best. It is very easy to find apps for pediatric speech therapy, even apps for adult language therapy. There are apps for language, articulation, AAC, voice, fluency, and a few for dysphagia, but not many. It seems that few therapists are using their devices for dysphagia therapy. In lieu of the small number of apps available for those of us specializing in dysphagia therapy, we can very effectively use our iDevices for treatment.

One feature that comes with any of the iDevices is the notepad. This looks like the yellow legal pads that I’m sure we’ve all used. You can use the keyboard or dock your device to a keyboard to type notes. Once these notes are done you can then choose the option to print or you can email it to yourself to print. You can also use Evernote (which is free) to create documents and access everything from any of your smart devices or from the computer.

I use Dropbox quite often. Dropbox is a cloud storage app. I have it installed on my computer, iPad, iPod and Android phone. I save files from my computer including journal articles, forms, documents, etc and can access them through any of my mobile devices or can access them via the internet on any computer. In addition to Dropbox (which is free for 2 gb), I use Carbonite. Carbonite is a yearly subscription (around $60 a year) that is a backup system for your computer, it backs up all of your documents, plus you can log onto your account from any computer via the internet to access all of your backed-up items and there is an iOs and Android app to access your files from your mobile device.

Dysphagia2Go is the new Dysphagia evaluation app that lets you use your iPad during your Clinical Dysphagia Evaluation to write a report with all of your findings. If you already have a computerized version of your report, you can email the results to yourself and copy and paste your findings. This app is available through SmartyEars and will have some exciting new updates soon!

iSwallow is available for Apple devices. iSwallow is a free app that allows you to show videos of each exercise for your patient and allows your patient to track their exercises and lets the therapist see how many times each exercise was completed at home. This hasn’t been a very functional app for me; fortunately it was free. You have to email the company to get a password to unlock the app and I tried many times, unsuccessfully, to get the password from them. Fortunately, I ended up finding another therapist that had the password to get it. Also, it would be helpful if you had patients that owned iDevices so that they could utilize it. At this time, I’m not willing to loan out my devices to allow patients to track. Most of my patients are 70 or older and don’t own iDevices.

Lingraphica offers 2 apps for dysphagia. One is a communication aid for the iPhone/iPod Touch that can also be used on the iPad. It allows a patient with dysphagia to communicate regarding their dysphagia, for example, “I need my dentures” or “I need to be sitting up to eat”. This would be helpful if you have an aphasic patient with dysphagia that would be able and/or willing to communicate these items with others. Lingraphica also has an oral motor app which has videos of each exercise being completed.

There are also several apps which show the structures, from a scope view. You can use iLarynx, LUMA ENT and URVL to look at the structures, or to use for patient education. They are also fun to play and see if you can “insert” the scope appropriately.

Lab Tests is a relatively inexpensive app, I think it’s $1.99 that describes the lab values and has normative data for lab values. This is nice if you work in an acute care hospital, where they typically draw daily labs to interpret what the lab values indicate.

Pill Identifier lets you search medications by shape, color or score. Telling you what the pill is, what the indications are, how it is available OTC or prescription. You can view images of the pill or look at information of each pill via Drugs.com.

3D Brain is a wonderful view of the brain to educate patients on lesions and where their lesions are located. It’s also a fun app to play with giving you views of the brain and descriptions of the areas of the brain.

I’m sure this is not a comprehensive list of the apps however, hopefully it’s a start to help you utilize your iDevice in your dysphagia therapy. Also, keep watching SmartyEars for possible new dysphagia apps.

 

Tiffani Wallace, MA, CCC-SLP, currently works in an acute care hospital in Indiana.  Tiffani is working to specialize in dysphagia and is working to achieve the BRS-S.  She is also a member of the Smarty Ears Advisory Board and co-author of Dysphagia2Go, and has a website about dysphagia, Disphagia Ramblings.

Recent Dysphagia Surveys

(This post originally appeared on Dysphagia Ramblings)

I have often wondered what others that work in the area of dysphagia do during therapy.  I always want to know what tools they use and what books they recommend, so I made a survey.  Actually I made two.

First, I sent out 75 surveys, in the surrounding areas in Indiana (mostly central).  I received 13 of the surveys.  Ok, 12 because technically I did one as well.  Most of the surveys came back to me partially completed.  I have the results posted on Scribd.

As a whole, we had an average of 10 years of practice, with the shortest time being 2 years and the longest being 30 years or more.  Most therapists work in a SNF (Skilled Nursing Facility).  One concerning factor for me was the lack of use of a standardized bedside assessment.  In our realm of changing and more evidence-based therapy/healthcare, can we really continue to afford to use only our judgement with no real data to back up our findings??

Another concerning finding to me is that the most widely used therapy technique is diet alteration at 85%, which tied with oral exercises.  Perhaps, a new survey should be devised to determine what people consider oral exercises.  I realize that in SNF’s there will always be those patients that require a diet change and are not appropriate rehabilitation candidates, however SNF’s are also becoming widely known for rehabilitation.

Techniques that actually engage the swallowing function and tax the system to bring about an actual change, such as the Mendelsohn, the effortful swallow, etc, were only reported to be used 46-38% of the time.  I guess this would also explain why the average percentage of return to a normal diet was only 50% with most likely, spontaneous return accounting for some of the return.

Expiratory Muscle Strength Training (EMST) is an emerging therapy incorporating respiration strengthening with swallowing exercises.  Items such as The Breather were only incorporated into therapy by 1 therapist.  Of course, keep in mind, this was a very limited survey response, it still, I believe, paints a big picture of how our therapy looks.

With the limited number of surveys that were returned to me per mail, I decided to also create a survey by Survey Monkey.  This survey had a response from 44 therapists.  Again, the majority of the therapists from this survey work in a SNF.  The most widely used therapy “tool” is tongue depressors.  I’m guessing because it’s the most accessible tool we can get.  The Breather/Spirometer for EMST was still fairly low on the list with 14-17% usage and the Iowa Oral Performance Instrument (IOPI) was at 9.5%.

Again, the most popular therapy technique is diet alteration at 95%.  Some of the rehabilitative strategies we use such as the effortful swallow, Mendelsohn, etc.were used by 50% or more of the respondents.

I think that one important thing we can learn here is that diet changes, head turns, chin tucks, double swallows are not “rehabilitative”.  They create a safe swallow for the present time while we rehabilitate the swallow for a diet upgrade.  While we may have our patients on an altered diet or have them employ compensatory strategies, we also need to work the patient, use that effortful swallow, the Mendelsohn.  Work the swallow system and make it work like it should.  That is rehabiltiation.  When we bring about a change, we rehabilitate.

Most of us do recommend The Source for Dysphagia by Nancy Swigert as our favorite book.

I think the main thing we need to ask ourselves when treating our patients with dysphagia is, “Am I doing everything I can to rehabilitate my patient?”  Then ask yourself do you feel comfortable in saying yes you are.  Treat your patients as you expect to be treated.

Tiffani Wallace, MA, CCC-SLP, currently works in an acute care hospital in Indiana.  Tiffani is working to specialize in dysphagia and is working to achieve the BRS-S.  You can find Tiffani’s blog at http://apujo5.blogspot.com.