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Intro

Kate Grandbois: Welcome to SLP nerd cast your favorite professional resource for evidence based practice in speech, language pathology. I'm Kate grant wa and I'm Amy 

Amy Wonkka: Wonka. We are both speech, language pathologists working in the field and co-founders of SLP nerd cast. Each 

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Episode

Kate Grandbois: Hello everyone. Welcome to S LP Nerd Cast. I'm so excited for today's conversation. I am in a room with three brilliant human beings who have had me bending over in stitches with laughter for the last 10 minutes. Uh, I am very excited today to [00:02:00] welcome Sarah Penrod, Dorie Fort and Lindsay Griffin to talk about a tool they developed related to tracheostomy patients.

Welcome Sarah, Dory, and Lindsay. 

Lindsay Griffin: Thanks. Thanks for you. 

Kate Grandbois: So before we get started today, I wonder if you all could tell us a little bit about yourselves? 

Dory Forgit: Yeah, sure. So I'm Sarah Penrod, and we are coming at you from Maine Medical Center in Portland, Maine. A level one Trauma and Certified stroke Center, um, cardiac Center of Excellence.

And Dory is my colleague and work best friend. And we've been here. Several years, almost, almost 10 years for you. A little bit less for me. And, um, we specialize, we see adult patients, we specialize in dysphasia and tracheostomy care. And, um, we are really looking forward to talking about this tool. Yeah, agreed.

Lindsay Griffin: Dory, do you wanna add anything or should [00:03:00] I start talking? 

Sara Penrod: Um, you can start talking. 

Lindsay Griffin: Okay. I'm Lindsay Griffin I am an associate professor at Emerson College in Boston. And, um, I, my clinical and my research areas of interest are related to dysphagia. Um, Sarah and I used to work together clinically many moons ago, which is how I got involved in the project.

Kate Grandbois: Wonderful. And two out of the three of you have been on the Nerd Cast before Dory. We're so excited for your first voyage in in Nerd Land. Yeah, it's gonna be super fun. Um, we usually 

Sara Penrod: enter Nerd Land. It's usually is so main here. 

Kate Grandbois: That's awesome. Um, before we get started, I do need to quickly read our learning objectives for the day learning objective number one, identify at least four research-based findings that impact the evaluation and treatment of dysphagia in tracheostomy patients learning.

Objective number two, analyze [00:04:00] clinical indicators impacting appropriateness for oral intake trials for tracheostomy patients and learning. Objective number three, discuss the relevance of a decision tree in guiding the care of tracheostomy patients in current clinical practice. For anyone listening to this episode who would like to learn more about the financial and non-financial disclosure disclosures of everyone on this panel today, including myself, all of that information will be available on the website.

And if you would like to use this episode for ASHA's CEUs, the information to take the post-test will be in the show notes and available on our website as well. Okay. Without further ado, I would love to start talking about how you all came to develop this tool, and I'm gonna be a little bit more specific and ask about the problem that you identified when working clinically.

As the rest of the audience knows, I am not a med SLP, so I am very much looking forward to hearing about the [00:05:00] the real world clinical problems that you were experiencing in a way that I can relate to. 

Dory Forgit: Yeah. You want me to take this one? Sure. Yeah. So at the time that I came to Maine Medical Center, we had a pretty small group, five SLPs.

And over that first year, we hired a bunch more SLPs and we turned into about a group of nine. And what we were noticing is that some SLPs were comfortable going in and evaluating tracheostomy patients right after the trach tube went in, even if patients were still on the ventilator. And some SLPs, it was their practice to defer the patients and not evaluate them, not see them until the patients were wearing the speaking valve.

And so. We, we started to look at this problem as a potential difference in outcomes, right? So if some patients are being evaluated really early in their stay, we know that the research supports seeing patients earlier. How can we get this timeline more consistent? And what would [00:06:00] be the, the outcomes for patients if we did find a way to get these timelines more consistent?

So we decided to look into the literature and see what the best practice recommendations were for SLPs being involved for tracheostomies patients. We, we realized that all the SLPs had kind of different background training. So we'd all come from different places or had been here for, you know, the entirety of our careers and, um.

What would be the process for getting all of us SLPs on the same page so that one patient wasn't, you know, being deferred for weeks and weeks and then potentially ending up with a disuse dysphagia and the next patient on the same unit, potentially being seen by a different SLP was being evaluated early, started on a PO diet early, potentially avoiding a PEG tube or a, a long-term feeding tube in the belly.

So when we started to notice these major discrepancies is what really gave Dory the idea for a decision tree to get us all on the [00:07:00] same page. 

Sara Penrod: And it was really, I, I remember when the moment when Sarah and I were like, oh, whoa, we should do this. It was, um, Sarah was presenting with a group of PTs and OTs and they were talking about, um, a decision tree they had on early mobility in the ICU, um, mobilizing ventilator patients called the red light 

Dory Forgit: stoplight, 

Sara Penrod: the stoplight tool.

And we both looked at each other and it was like, do you remember that? Mm-hmm. We were like, oh my God, this is exactly what do we need this for the trach patients? 'cause it was something we'd been talking about how there was such a range of comfort on how we treated these patients and how it was like such a problem and we were just like, whoa, this is exactly what we need.

Mm-hmm. For these trach patients. So that's kind of how it started. That's how the, the, the decision tree and the idea of it being a green light tool. So instead of stoplight with the green light was to like empower 

Dory Forgit: Yeah. 

Sara Penrod: These patients like, go ahead and go. Yeah. Yeah. 

Kate Grandbois: That's awesome. [00:08:00] So, to say this back to you, as I prefaced earlier, to make sure I've understood, because there are so few medical things that I understand.

Um, to say this back to you, there was some discrepancy related to the clinical care that your tracheostomy patients were receiving in the hospital. And depending on the SLP, uh, depending on which clinician that patient received, they would end up with a sequence of clinical care decisions that resulted in very different outcomes.

Right. So patient A, uh, would have one outcome and patient B would have the other outcome. I'm wondering, first of all, if that isn't incorrect, please let me know. Second of all, I'm wondering if you could tell me a little bit about what, you mentioned the word empower. What are the differences or what do you think the barriers were to these clinicians implementing this, implementing their knowledge in different ways?

Were they trained differently? You also mentioned like a comfort. What was going on that you, what were some of the underlying [00:09:00] things going on that contributed to this? 

Sara Penrod: Well, we actually, we, as part of. The process. We did a survey to kind of get an understanding of, of where clinicians thought the appropriate starting point was for certain things, like, um, starting PO trials or trialing the pasir valve or when to do a modified barium swallow.

And a lot of it had to do, like Sarah mentioned, the culture of where they were trained, whether they had been at Maine Medical Center, the entirety of their career, whether they had been trained at like a, an acute, a more acute hospital elsewhere. Um, so people had a variety in their training where they were told like, oh, you can't, like when I started here, I had always been told you can't start PO trials until their cuff is deflated and they're wearing the speaking valve.

And that's like where, you know, the SLP started and. So it was just, I mean, that I changed my practice [00:10:00] pretty quickly here, but that's, there was just such a range. And then, you know, a lot of, a lot of clinicians who were kind of newer or just had different experiences just, just weren't comfortable with trachs, tracheostomy patients.

So they just were just kind of waited until they were handed them already wearing a speaking valve and they felt comfortable that they were stable and like were totally ready and safe to start eating and that's when they would see them. So, so we did a survey that kind of showed this huge range of really comfort of when they felt it was safe and appropriate to start seeing these patients.

Dory Forgit: And I think a lot of it had to do with what respiratory Therapy's involvement was, right? Yeah. Like, 

Sara Penrod: yep. 

Dory Forgit: Excuse me. So. In some places, SLP is very different to respiratory therapy. So respiratory says I'm in charge of the trach, I'm in charge of the cuff, I'm in charge of the speaking valve, I'm in charge of the cap.

And SLPs are different and say, okay, you let [00:11:00] me know when it's a good time and we'll get it going. And then in some facilities, the culture is that the speech pathologist is a little bit more, not the owner of the trach, but certainly guiding in the therapeutic involvement, uh, providing all the education on, well, what does it mean to have the cuff cuff inflated?

And why is this patient's cuff inflated? When is it appropriate to trial a speaking valve? And what are the indicators that a patient is tolerating or not tolerating? So I think a lot of it was around this. Sort of culture change mm-hmm. At a time when the respiratory department wasn't as fully staffed and speech pathology was becoming more staffed.

We have a little bit more time that we can spend with patients than respiratory does a lot of time. So, um, I think a lot of things were changing at the same time. And if you work in a facility where usually SLP doesn't deflate the cuff and usually SLP doesn't suction, then that can be kind of a culture shift to change.

And then there are some SLPs who are like, well. [00:12:00] Why would I be the one to do that when respiratory is in charge of it? And then you have a conversation, we'll talk about buy-in a little bit later, but a conversation with the, with SLPs who kind of think that way and say, well, what happens if we do that a day earlier?

And what about if we're thinking about it in a different way than the respiratory therapist is thinking about it, like the cuff being inflated. In general, you'll see a lot of facilities where once a patient is off the ventilator, the cuff is down and that is that. And then there are other facilities where they leave the cuff inflated until someone suggests that we take it down.

So there, there's really culture changes that can be kind of jarring when you go from one facility to another. And when you actually look at the literature, you go back to the literature, that should always be where we get our decision making from. 

Kate Grandbois: It's like you read my mind. I was just thinking about, you know, at what phase the evidence comes in, you know, came into [00:13:00] your decision to move forward with creating a tool.

But before we talk about that, I just wanna hold a little bit as space to highlight the importance of culture and, and how that shapes the decisions that we make. And I think every speech pathologist listening to this, if you used to work in a school or you work in a private practice, or you work in a different type of medical facility that is in an ICU, uh, I think all of us can resonate with the idea of this is what we do here.

This is the, this is the norm, this is the standard of care. And the eye-opening realization that that standard of care isn't necessarily what is considered best practice from research. So. As you've kind of, you know, you're going, you have this aha moment, uh, from your PT colleagues thinking about creating a tool.

You've identified this discrepancy and how it has an an impact on patient care. At what point do you think, well, what does the literature actually say about this? What can you [00:14:00] tell us about that process? And then, and then what the literature actually says. 

Dory Forgit: So that's, that's the first place that we went.

Um, and we can actually submit our references to you, Kate, for your listeners. Um, and we have, along with the green light tool, which we can share with people a, um, a reference, like a clinical reference sheet that, um, gives the best practice information. But, um, yeah, we did an extensive, an extensive lit search on, you know, best, hold 

Sara Penrod: on a second.

Sarah did an extensive list. Like this is not, we'll talk about where our skill sets divide. Mine will shine later. But this whole research lit search, this was all Sarah. I just wanna be clear on that one. 

Dory Forgit: Yes, Dory has more useful skill sets than, than mine, which include reading. Um, but yeah, we'll talk about these, these pain points a little bit later.

But the notion of, okay. There are very specific steps that that [00:15:00] happen with a tracheostomies patient from trach insertion to decannulation. So we basically broke the lit search down into when, when does best practice support doing these main things? Deflating the cuff, trialing the speaking valve, downsizing the trach, trialing the cap and dec cannulating, and then looking at research surrounding swallowing in those contexts.

Now, the research is totally disparate on tracheostomy tubes, and this is because a lot of times the tracheostomy tube is the only thing these patients have in common. There's many reasons that a patient gets a tracheostomy tube, and there are many things that patients go through leading up to a tracheostomy, such as multiple and prolonged intubations.

There's actual, you know, risk for laryngeal trauma to the airway. So there's all kinds of things that patients go through. I mean, head and neck cancer patients requiring tracheostomy because of an obstruction, brainstem stroke. Uh, patients who are not breathing spinal cord injury patients. You, [00:16:00] we talk about tracheostomy as this one thing, but really these patients are wildly disparate.

So it makes sense that the literature is as well. So some literature findings suggesting that the tracheostomy itself causes dysphagia. Other extensive literature showing the tracheostomy tube does not cause dysphagia, but rather what was the reason that the tracheostomy tube was put in in the first place?

Those things can, um, cause dysphagia in isolation. So I think our big takeaway, and we'll get into how useful the tool is, but. These patients need to be assessed on an individual level and not just treated as a whole, meaning a tracheostomies patient. Um, it's so important to look at these patients as individuals and, and the tool is meant to help guide SLPs through those main pain points and, um, encourage the SLPs to evaluate anyway, yes, there is risk.

Yes, there is, you know, multiple factors. [00:17:00] Document it, assess it, measure it, and then reassess. Um, and that's what I think that the tool is really good for. 

Kate Grandbois: What I think is so interesting about this is, you know, there are so many aspects of speech language pathology that are a little black and white.

I'm gonna use the articulation as like the classic example, right? Not that it, there isn't, you know, there aren't maybe gray areas, but I love the description you gave with, you know, just because a patient has a tracheostomy. Doesn't mean that they have etiology. That is anything like any, any other patient with the tracheostomy.

So I think that that's really interesting and you did such a great job describing that. I wonder if, now that we kind of see the lay of the land of the reasons why you needed a tool to help clinicians kind of wade into the gray and and increase their confidence with how to navigate some of this complex clinical decision making.

Can you tell us a little bit about the tool itself? So what [00:18:00] is it, how is it used, and anything else that you can share about it would be helpful. 

Dory Forgit: Yeah. Go for it. Okay, so this tool is based on a stoplight or a green light traffic light. Green light means go yellow, light means proceed with caution, and red light means stop.

And we structured it mainly to give SLPs a, a consistent rationale as to when to defer evaluation. So the notion is we should be evaluating these patients, green light or yellow light. We should be seeing these patients, where are the red lights that say we really shouldn't be seeing these patients. We should be deferring them.

And through the the lit search that we did, we found that really there's no reason not to evaluate patients aside from when they're on full mechanical ventilation and they're being actively sedated. So these patients can't, they, they lack the prerequisite skills to participate in any kind of assessment, right?[00:19:00] 

Patients who are off sedation. Even if they're on the mechanical ventilator, can still be assessed with a thorough chart review and case history, potentially an oral me and cranial nerve exam, which we know can correspond to oral in pharyngeal dysphagia secretion management, both oral pharyngeal and tracheal secretion management.

What, you know, what is the patient, how is the patient responding to their secretions. Um, we can look at their ventilator settings and compare them to previous, um, to try to mark, you know, improvement or changes in their course. We can talk to respiratory staff about, um, once they're off the ventilator timeline to deflating the cuff.

So if patients are dealing with, um, a lot of oral secretions and you're worried about aspiration, you might want a patient to leave the cuff inflated. But if the secretions are already in the chest already in the pulmonary cavity, then perhaps we talk about deflating the cuff to kind of help get the air into the, um.[00:20:00] 

Into the upper airways and, and provide patients that stimulation. So each of these pain points is, um, addressed in the green light tool. So the tool itself, green light go, meaning evaluate and potentially offer PO trials during your evaluation. Yellow light, definitely go see the, the patient, but maybe proceed with caution when it comes to eating and drinking.

So for example, if a patient lacks the prerequisite skills, right, you can't keep the patient long awake long enough to even try a wet swab. The patient doesn't follow any directions for an oral ME exam, doesn't respond reflexively to a spoon or any kind of oral stem, then you perhaps would not give a patient more to swallow.

Right? So there's, there's the green light tool itself and then there's a clinical appendix that that offers some of these suggestions. So. Sure the tool tells you go ahead and evaluate, but what am I supposed to evaluate if I've never evaluated a patient on a ventilator before? [00:21:00] Where am I supposed to start?

What am I looking at? So the clinical appendix actually gives SLP suggestions as to what skilled assessment to do and what to document in the note. And, um, Dora's big on the, like, what next? What's the barrier? What are we waiting for? What's the next thing that you'd want? For the next SLP to see, to be able to say, okay, I can proceed to the next.

Sara Penrod: And that was a big thing. And it like, the way our hospital works is we don't hold on to the patient from start to finish. If they move units, they move to a next SLP. So we always, I'm always big on the benchmarks, like, what does better look like? What, what does the next, what do they have to achieve to get to the next step?

So what's preventing them from using the speaking bell? What's preventing them from being appropriate for PO trials? You need to have that documented so the next SLP will know. And so the green light tool can help guide that sort of understanding of, of what better or worse might look [00:22:00] like 

Dory Forgit: In the tool, there's a, a ventilator tip sheet so that SLPs can kind of gauge benchmarks on, you know, how much volume a patient needs, how much pressure, how much oxy oxygen, what their respiratory rate is, what the different ventilator settings are, so that you can kind of have a hierarchy of how severe the patient's respiratory failure is.

Um, so that's included as well as part of the tool. 

Kate Grandbois: I wanna talk about what variables you all included, but first I wanna ask a question. So this tool we've already reviewed, you know it, it's main purpose, right? Increasing confidence and SLP is giving a decision tree, critical thinking, critical decision making.

Is it used across teams or is it used just for the one person, the one time? What is the penetration, I'm gonna use the word penetration. I'm sure I could think of a better word. What, what is the, how, how, how much is this decision tree diffused throughout [00:23:00] your organization? Like between departments? So if you're in the ICU or other SLPs outside of the ICU also using it.

Sara Penrod: Yeah. Yeah. I mean we're, we're not a very big department. There's about what, 10 adult SLPs? 

Dory Forgit: I think so, yeah. 

Sara Penrod: And we rotate frequently throughout the, the, the ICU and different ncs. Um, and so it's, it's used across, it's, we all use it. I would say use this tool depending on where we are. And it's really, it's, it depends.

I think it's used, it's, everybody knows about it. Everybody uses it when they're at a point where they're like, I'm not sure what to do next. You know, it's, it's, we've all used it so much that, um. It is not, you know, accessed regularly anymore, I would say by, certainly by people who have been here long enough.

But it's, it's something to pull out when you're like, I'm stuck. Like, I don't know what to do next with this patient. Um, [00:24:00] I, I don't have anybody to ask, you know, uh, but it, it, it could be a patient just in the ICU, it could be a long-term trach that you're, is sort of like at a pain point, I guess it's, it's, I would say diffused throughout the hospital, really, depending on what's happening with that tra Gasm patient.

Dory Forgit: And it's become part of the culture now. Yeah, absolutely. We know that, okay, just because this patient's on the ventilator doesn't mean we don't see them. There are other things that we're looking for. There are other benchmarks to, to look at. So, um, it, it's, it's culture change now at this point. Yeah. It's certainly very much ingrained, very much.

Kate Grandbois: That's awesome. I wonder if you could talk to us a little bit about the variables that you look at. 

Dory Forgit: Yes. So a lot of these, a lot of these came from the literature. This is how they kind of measure SLP impact, um, in patient care. So timeline, some the patient outcomes that we looked at were timeline to [00:25:00] speaking values, timeline to decannulation.

So we wanted to know, is this shortening the time that patients are not able to talk? Is it shortening the time that the tracheostomy tube is actually in place? We looked at, um, timeline to a PO diet. So how long were these patients spending NPO? And then, um, we looked at hospital length of stay. Um, a lot of the things that we looked at were time from SLP eval to the next thing.

So from when the doctor put in the consult for the SLP department, when did the SLP go see the patient? So our, our hypothesis was that prior to the green light tool, this would be a really long period of time, and that will, the tool would help us to shorten it because giving LPs the tools for what to do at the bedside, they'd be more likely to go see the patient.

So that was one of our hypotheses and we had thought that the tool would shorten all of the, improve all of the outcomes [00:26:00] for the patient. So shorten the time that they can't talk, shorten the time that they can't eat, and shorten the time that the, that the tracheostomy tube was in place in general. 

Kate Grandbois: So, going back in time and kind of thinking big picture about how you all moved through developing this tool, it sound, you, you developed the tool and then you, then you tested it, it sounds like.

So when you and I, this was published in a journal, we should have said that at the beginning of the talk, I'm realizing. And so anyone who is listening and wants to read more about this, a the tool itself, there is an article that came out with these lovely human beings, um, as authors that we will link in the show notes.

So when you decided to test the tool, did you have support for that? How did that end up happening? 

Dory Forgit: Well, like test, do the research or, or roll it out. Well, we [00:27:00] definitely had major support. So, um, our director is fabulous about, um, quality improvement and consistency among treating therapists. So we brought the project to the director and got pretty quick approval to work on this.

And then I think a lot of what, so Dory is, um, very specialized in quality improvement. And so a lot of what you've, do you wanna talk about the training program that we did with the SLPs? 

Sara Penrod: Yeah. So, uh, the, the way we rolled out in the department to, to, first of all to get buy-in and, and also to make sure that it is easily understood and, and worked smoothly, um, and is usable by SLPs.

Um, we, we sort of introduced it as a quality improvement project and we sent out a survey measuring the, their, like I said, their, their. Comfortability confidence in, in, um, in when to, to treat, uh, tra tracheostomy patients. And then we, [00:28:00] we, I'm forgetting how we even did that. 

Dory Forgit: We did like training 

Sara Penrod: sessions.

We did, we, that's right. We did a training session and then we did chart audits of their notes to make sure that they were consistently using sort of the rationale that explained in the green light tool. And we did that over a series of months to make sure that, that, that we were all sort of consistently using the, the, the framework of the green light tool as a department and, and we that everybody kind of.

Was on the same page and there was good buy-in. And then we redid the survey and it was really, really impressive how that the, um, the consistency of use of the tool, but also everybody felt much more comfortable and on the same page with when, when to what these pain points sort of evened out. Um, and then we started the research part of it, right?

Dory Forgit: Mm-hmm. Yeah. Yeah. So we got IRB approval to collect the retrospective data and then the, well that was both sets of data were retrospective 'cause [00:29:00] we waited for the patients to leave the hospital. We collected a group of data, that was before we started using the tool and then a group of data after we started using the tool.

Kate Grandbois: So I wanna talk about the research in a second because I think that that's obviously very important when you have, you know, a, a clinic, a tool that can be clinically applied that has some data behind it, right? That's, that's what we all want. Um, but before we talk about the research, in thinking about the clinical application of the tool, before you guys got to the IRB approval phase, how did you introduce this to your team?

What was that like? You guys had a little aha light bulb moment. You, you developed it, you thought about all the variables that you wanted to include, and then what did you do over, over lunch? Hey guys, we found like this way better way to do this. What did, what did you do 

Sara Penrod: to get buy-in? We did, there was a lot of, there was a lot of like, workshopping even, even leading up to it, you know, uh, when we were creating it, you know, Sarah would come up with these [00:30:00] ideas and it was a lot of me being like, well, you know, like, how about this?

You know, like. Um, sort of devil's advocate, like, would, would we say it this way, type thing. Um, and then ultimately, like I said, we rolled it out as we have, um, uh, an improvement board, uh, standard throughout our hospital called the, the Gemba walker used to be called the MKPI, but like this standard thing throughout our entire health, um, medical system really that that's established.

And we just kind of rolled it out as like, oh, this is a quality improvement project. And so it was, it was like a process they were familiar with. And I think that's kind of how we did it. So it wasn't like, this is mandatory, this is the new thing. It was just like, oh, this is our idea. We wanna kind of see how it works and this is why.

And it's not, it's not required. You don't have to use it. We want you to use your, your same clinical judgment. It's a decision tree, it's not a protocol. You know what I mean? [00:31:00] So. It's just a, it's, it's something to, to help guide decision making but not re a requirement and 

Dory Forgit: pointing out the differences and the discrepancies in when patients are being seen.

I mean, the SLPs are pretty amenable to, yeah. Like, okay, if if there's this big of differences in clinical practice, we should definitely be talking about it. Um, 

Sara Penrod: and it, like, it wasn't punitive. It wasn't like we're doing chart audits and speaking to you directly. It was just everything was anonymous.

Dory Forgit: Mm-hmm. 

Sara Penrod: And it was 

Dory Forgit: like, and it was at a time where the, the group had grown, so it was kind of almost like a new group of SLPs. Since that time, I think we've grown twice more. 

Sara Penrod: Yeah. 

Dory Forgit: And so now when SLPs are onboarded, it's like, Hey, we use this tool. This is part of, you know, the orientation process. And I think every SLP we've hired since then has been like, oh my gosh, this is great.

We didn't have anything standardized at my last hospital. Or, you know, I, I've never evaluated a patient on a ventilator. Um, so people have seen it as [00:32:00] something that is useful rather than something that's being forced upon 'em. 

Sara Penrod: Yeah. 

Kate Grandbois: And it sounds like you leveraged some structure that was already there.

Yeah. So your organization already has quality improvement initiatives. Yeah. And performance reports that are standardized for all staff versus, you know, talking to someone one-on-one in their performance review, being like, you're not doing this right. Do this better. Right. Yeah. Do you feel like those already established things helped facilitate some of that conversation?

Sara Penrod: Yeah, definitely. It was certainly wasn't something we could be like, this is like, we came up with this. We think this is a. Better. We want you to do it the way we do it. Like that was not gonna work. You know? So it had to be, um, it had to be, we had to present it in a way that there would be buy-in, that people would be like, this is something that I wanna do too.

And not, Sarah and Dory said that we have to do this. Like, that was not gonna work. Yeah. You know, so [00:33:00] it was, and I, you know, I think, I think doing it in a, in a quality improvement way or, and it, it really is optional. It's not required in our, in our department at all. It's, it's suggested, but we don't consistently go through and check and make sure people are doing it.

But it, it, it contributed significantly to a culture shift here. 

Kate Grandbois: I think, you know, it sounds like your group of LPs is very much like every other SLP I've met, which is wanting to do good. Yeah. Wanting to, wanting to do right by our patients wanting to use best practices. Right. So I, I think it's awesome that you were able to create something new and leverage some things that were already established.

You know, some infrastructures that were already established to kind of present this new thing in a way that was neutral and positive. Um, that kind of helped facilitate a little bit of that buy-in. Um, okay. Now I wanna shift gears a little bit and talk about the study. So, kind of moving along a timeline, you identify all of these issues, [00:34:00] these discrepancies, how they impact patient care.

You do a lit search, you create this tool, you leverage quality improvement to kind of diffuse it out to all of your teams. You train everybody, you get buy-in, and then you think, huh. This is kind of cool. Maybe we should study this or test it or, or, or look at you. Sarah, you already mentioned some of the variables that you looked at, how you had support from your administrators to, um, to move this into a research project.

How did, what did that look like? I mean, I feel like that is something that a lot of SLPs would love to do, you know, as clinician researchers and don't necessarily have the opportunity. So can you tell us a little bit about that process? 

Dory Forgit: So, we are really fortunate here being a teaching hospital that we have, um, the Center for Nursing Quality and Excellence that provides PhD level support for getting your application through the IRB, which is the first step.

So we had to put in. [00:35:00] Um, an application to look back at these charts, charts retrospectively, it's considered non-research. It's exempt from being real research because the, the charts are already closed. We use no identifying information. Um, but the process is pretty hefty. And the IRB looks at all applications the same way, regardless of it's pharmaceutical or non-patient centered research.

Um, so we had a lot of help getting through that. And then we worked, I tapped Lindsay to be like, will you help us think about which variables we wanna look at to do the math please, because we don't wanna do math and, um, statistics and those types of things. Um, so we were really lucky just to have, like I said, that the, the research, um, portion of the hospital and then to have a PhD as a friend is like really useful.

So, um, Lindsay, I think we'll talk about our math when we get to it, but we. It was a lot of work. It is a lot of work. I think the IRB sent [00:36:00] back our proposal a couple of times, so you have to, you know, edit and modify to get the, the numbers just right and well, where are you gonna store this data and how are you gonna collect this and how will this be de identified and stuff like that.

So it's very thorough. But again, being a teaching hospital, they want clinician researchers, so it's encouraged. Um, I think now that I've been through it a few times, I'd be more than willing to talk to someone about it or help someone out with it because it, it, I think it's really empowering to be able to, and important, right.

You know, it's not, it's not necessarily great to just create a, a tool and throw it out there. You have to have these validation measures. So, um, it, it, it's been a really good experience. 

Kate Grandbois: That's awesome. I would love to hear a little bit about, you know, thinking about where you were in this timeline, wanting to move it forward and validate it through research.

How did you decide what variables to look at?

Dory Forgit: I mean, I [00:37:00] think because what we thought the tool would do, we were, we were basing it on our hypothesis. We thought the tool would have specific outcomes like shortening those, the, those pain points, not allowing patients to talk, as we know, adds to delirium and all kinds of other side effects. So we wanted to know is getting involved earlier helpful.

To, uh, improving patient's communication and timeliness to communication, you know, speech and swallowing services. Of course, we're trying to resume an oral diet, so I think we picked the ones that we thought would have the most outcomes for patients. 

Sara Penrod: The, the pain points we identified on the, the clinical support appendix matched exactly with the pain points that came up in the survey of the clinicians in our department where that had the biggest discrepancies on where our comfort level was.

So it was, it was, and that's kind of where we identified our variables too. So it was pretty consistent, um, where [00:38:00] we thought it would be and where it sort of, the department felt it was too. And where we collected our information, where those, those areas where the biggest decisions were made by SLPs, I think.

Dory Forgit: And there's other literature that talks about timeline to speaking valve and, um, timeline to PO diet. As being main goals for SLP involvement. So pretty standard with other research as well. 

Kate Grandbois: So you get the IRB approval, you do retroactive chart reviews as part of your data collection. And, and what did you find?

What was the math? Lindsay, do you wanna tell us about the math? 

Dory Forgit: Well talk about the math, Lindsay. 

Lindsay Griffin: Sure, sure, sure. I'll talk about some math. Um, so like Sarah and Dory said, they looked at the charts and they got dates. So on November 7th, this patient, what a consult was placed on December 6th, we actually saw the person December 7th, we started them on a diet, whatever.

So [00:39:00] they got all of these dates and then they gave me the, the number of days in between these different points. Um, and so there were three groups. Which they had alluded, they have alluded to also. So they had, um, they collected data from 100 patients from before they rolled out the, um, green light tool at Main Med.

And then once the Green Light tool had been established and used regularly with their staff, then they looked at 50 patients from about a six month period between rollout to six months. They, they, they've identified 60 patient, I'm sorry, 50 patients. And then, um, another 50 patients between the six and 12 month, um, uh, post rollout.

So there was a pre rollout, and then there was six months after and then 12 months after. So those are the, the three different time periods. [00:40:00] And then my data was just time, number of days between these different things. So I used SPSS as as, as you, as one does, um, and, and identified first the thing for one of the first things I tried to look at was because there are these three different groups, is there significance between the three groups?

Because if the groups themselves are significantly different from one another, then your data could, your outcome measures could be not be as relevant because the groups themselves were different. Um, so the, um, we looked at their age, uh, their sex and their length of stay between the three groups. Their age was not significantly different.

Their sex was not significantly different, but their length of stay was significantly different. Um, where participants who were in times two and [00:41:00] three, so after the tool had been rolled out, had significantly longer length of stay compared to participants from Time one and which would be before the tool was rolled out.

And that lovingly corresponded with the COVID-19 pandemic. 

Kate Grandbois: Oh man. 

Lindsay Griffin: Yeah, yeah. Mm-hmm. So there's not much that can be done about that, right? Because it's just like retrospective data collections. But it's worth noting that for some reason the patients who were there, who were in groups two and three have been there longer.

So was it they were sicker? Was it that there was nowhere for them to go because of changes to the healthcare system following COVID? Um. Who knows. We did look at diagnoses between the three groups, um, and they were categorized in, I think, like nine different ways, like neuro trauma, lung disease, spinal cord injury, et cetera.

And, [00:42:00] um, between the three groups, there was no significant difference between, um, the, the, um, the groups based on diagnosis. So again, why were they there longer? Not sure their diagnoses were the same. That doesn't speak to the severity of their diagnoses and again, COVID, so. 

Kate Grandbois: Got it. 

Lindsay Griffin: Yeah. 

Kate Grandbois: So after this preliminary set of analyses, you're feeling like, okay, we can move forward with looking at whether or not the green light tool had a positive impact on other variables.

So what other variables did you look at? 

Lindsay Griffin: Yep. So, um, the dates were, when was the SLP um, consult placed? When was the SLP evaluation actually completed? So from like my own experience in clinical care, um, when you don't know what to do and you get a consult and you, and you're like, you do a chart review and you're like, oh, you know what?

This patient's on event I [00:43:00] can't see them. Or this patient's vent settings are too high, I can't see them. So you're deferring the evaluation versus actually completing the evaluation. So one of the things they, one of the dates that they, they looked at was when was the order placed and when was the person evaluated?

And not necessarily the reason for the difference in the time periods, but just what, what were those, um, differences between, between the different groups? Um, they looked at the date of when the person had a papier valve order PLA placed, when they had a capping order, um, when they received, um, PO trials when they had an order for a diet.

If they had a modified barium swallow, when was that? Um, when were they decannulated, if applicable, and if they had a feeding tube placed, a PEG placed, um, when, when was that completed? So as Sarah indicated, we [00:44:00] wanted there to, okay, before the Greenlight tool, people were waiting years, months, decades for SLP Care and immediately after the Greenlight tool was implemented, hours, hours went by, they were cured, all was well.

Um, that was not the findings, although that was kind of the hypothesis. Um, so the findings indicated that when the person received the trach surgically implanted, and then when the per and then when the, um, SLP evaluation, um. Happened, it was shorter following the inflammation of the green light tool. And then when the, um, provider placed the consult to, when the SLP actually evaluated the patient, that period was shorter.

So, and then all of the other outcome measures like time to when they get to eat, when they get to feed, uh, [00:45:00] um, a speaking valve, when they have capping, um, all of those things were not significantly different between the three different groups, but it did in the results do indicate that when, um, after the Green Light tool was, was implemented, patients were being seen earlier, which is.

An important takeaway, even if the other outcome measures the time periods weren't different, especially in the vein of understanding that patients were seeing, being seen earlier in their course of stay, which was ultimately longer. They had a longer course of stay. So they were getting earlier intervention from SLPs, um, after the SLPs had the, the tool and the empowerment to go see the patients and decide on what sort of clinical care is best for them.

Kate Grandbois: So I'm gonna ask a question and it could be a terrible one. I know everybody says there's no such thing as bad [00:46:00] questions, but sometimes I ask a question and I'm like, I just making myself look bad because it's a very, in could be a very uninformed question, I'll put it that way. So it, it sounds, just to kind of say this back to you, the findings of the study indicate that there is a, the period of time between initiation of SLP services and the actual SLP evaluation is shorter for patients.

Dory Forgit: Yep. 

Kate Grandbois: Why is that an important takeaway? What are the potential clinical outcomes or potential impacts of having a shorter period of time between when a patient sees an SLP? 

Lindsay Griffin: I can propose several. Um, first being, if you think about it from like a patient quality of life standpoint, if you were just sitting in the hospital twiddling your thumbs, waiting for the provider to come, and the provider's not coming because they don't know about you or they [00:47:00] think you're not appropriate, or whatever, the case may be appropriate to be seen, I should say.

Um. When, when the provider comes, um, and, and care is provided, certainly that, that is helpful in terms of, um, pro progressing you through the system. I also think that it speaks to, um, the providers being more aware of the role of the SLP in, in patients with TRAs, with tracheostomies. Um, if the, if the providers are putting the orders in earlier.

For speech to see patients, that must mean the providers see some value in speech coming. And so I think it gives SLPs a, a seat at the table that maybe they, they weren't having before. And then, um, I think it also speaks to this tool, providing the [00:48:00] SLPs with the comfort or the guidance to see patients earlier, whether or not, um, the patients are ready for, um, for speaking valves, cuff, deflation, PO trials, whatever the case may be.

Um, it puts the SLP on the treatment team at an earlier time. And, and so as the person is, um, you know, recovering, they have another person look another, another teammate looking out for them. 

Sara Penrod: I was gonna say something. Go ahead. I was gonna say too, just because they're not meeting those benchmarks doesn't mean that, um, education and therapy isn't happening, right?

Sure. So you can be providing education to family or to the patient if they're available cognitively for it as to like what could be happening or what the next steps were. You could be doing therapeutic po with that patient, doing communication. There could be so much happening [00:49:00] therapeutically for that patient that that is getting them very slowly to that next benchmark, but, but is very important to that patient's care that's happening sooner, um, by getting the SLP in sooner.

And there's a lot of education that around the trach that the, the, the speech pathologist provides that. That the physician and the respiratory therapist just isn't really available, um, to, to provide to the patient and the family. So I think there's that big piece there too. 

Dory Forgit: Mm-hmm. 

Sara Penrod: Is that what you were gonna say?

Dory Forgit: Yes, that's exactly what I was gonna say. Sorry. And if No, that's accurate. And, um, if there's not an SLP monitoring for those benchmarks, then there's risk of missing benchmarks and having patients. Miss those timelines unnecessarily. So certainly better to be involved early to prevent missing those benchmarks.

And also, you know, when you're managing tracheostomy tubes, oftentimes you come across something in your assessment that indicates a, [00:50:00] another specialist is warranted, like your nose and throat or GI or something like that. So all of these things being done sooner. We know that the data shows ultimately does shorten hospital length of stay.

So, um, even though we went through a weird timeline, and our, I will say, and we, we do mention this in the article, but our ICU grew double in size during and after COVID, we lost eight skilled nursing facilities through the COVID process. So we, we did look at patients that were similar, but we looked at, at them in a completely different environment.

And I. I almost think you can hardly compare the two, um, just based on how different the, the acuity is at this hospital. So, and of course I did want the green light tool to immediately cure all trach patients, but just because those findings were not there, I, I do still strongly feel that SLPs should be empowered to be involved early and [00:51:00] consistently with TRACHEOSTOMIES patients.

There's so much, um, that SLPs can be helping with. 

Kate Grandbois: And I, I was just about to say, you know, what you all found was relevant to the question that you asked. Right. But it sounds like there are a lot of other really positive anecdotal outcomes that you've described that haven't been researched yet. I will put an asterisk there with my finger in the air yet, because I know with every research question and every out, every research outcome, there are always more questions.

This is what I, this is what I have learned. And I wanted to ask a question about how it's contributed to clinical decision making. Um, in terms of, I mean, that would just be like another research question is how your SLPs have responded to it, um, or how it changes SLP practice in more nuanced ways that do contribute in positive ways to patient outcomes.

[00:52:00] Um, I wonder, just for the SLPs who are listening, as I mentioned already, the article that has the green light tool will be linked in the show notes for anyone who would like to read it. Um, I wonder if you could talk a little bit about how, for someone listening who has never used this tool, how it might contribute to different, you know, differing clinical decision making and other positive outcomes that are, that you've found outside of the study itself.

Dory Forgit: I think if you're an SLP working in a community where there's inconsistency in how you approach tracheostomy patients, this might be a good like journal club type thing. You know, can all the SLPs sit down together and take a look and see what the consensus is of the group? Um, I think for some groups of SLPs, the notion of swallowing on the vent is unheard of.

And for some groups of SLPs, it's already standard practice. Um. So if you're working in a group where it's [00:53:00] already, we already have, um, in our tool belt, a list of assessments that we do with ventilated patients, then perhaps your, your group isn't lacking in this area, but if, if you're dealing with any kind of inconsistency or, um, confidence deficit or knowledge deficit in what to actually do with the patients, okay, I'm, I'm comfortable being around tracheostomies patients, but what skilled thing can I offer to those patients?

Then the, the tool may be helpful and it's, it's not a long read and the tool's right in there, so. You may as well just give her, give her a read and see what you think. 

Sara Penrod: And I think, I think the notion of the green light tool, just looking, the, the whole idea of that outside of, of treating tracheoscopy patients, the whole idea of the green light is like looking at a patient and, uh, uh, uh, a diagnosis or a treatment that you're like a little bit uncomfortable with and, and saying, why would I not do that?

Like, what is the actual barrier? Is it because I'm uncomfortable? Like, [00:54:00] what is, what is the stoplight? Like what is it that's stopping me from doing it? And, and keep asking yourself that and making sure that the answer is something strongly clinical and not something a, a roadblock that you're putting up that's your own roadblock and not the patient's actual clinical roadblock.

And I think that's the biggest takeaway from the Greenlight tool that we try and instill that, that, that we were trying to instill. I think that that's where we're seeing that. Seeing a culture change within our department outside of trachs. Mm-hmm. You know, um, that's really important. 

Kate Grandbois: I, I, I love that the way you phrase that, because in so many aspects of our field, that intersection between competence or our feelings of competence, or dare I say, imposter syndrome and, and how that interacts with the decisions that we make, that impacts all of us as clinicians.

Mm-hmm. Right? Mm-hmm. Um, for an SLP listening, who's intrigued or is thinking that this tool might [00:55:00] be, um, a vehicle for a similar culture change, I wonder if you could tell us just a little bit more about the rollout. I know you leveraged quality improvement and that mitigated, you know, defensiveness and helped you get buy-in, but I see in the notes here that you went, that you took data for about five months to make sure that it was implemented consistently.

How long, like what was the training like to train people how to use this? 

Sara Penrod: Um, it wasn't, the training wasn't huge. It was, it was. One big, it was like a two 

Dory Forgit: one hour 

Sara Penrod: sessions, two one hour sessions 

Dory Forgit: with case studies. 

Sara Penrod: Yep. 

Dory Forgit: Here's the tool, read the case, what's the next step, and get everyone's agreement. 

Sara Penrod: And it was really more of, it was more of a conversation mm-hmm.

Than a lecture for sure. Mm-hmm. Again, we're smaller groups. It was like a, a conference room style presentation conversation. Um, there's some strong personalities in our group as you could imagine. So, you know, accounting for those personalities, a lot of [00:56:00] conversation. And then the data collection was five months, because we don't always have a lot of traches and most 

Dory Forgit: collecting data, you stop getting your target population, all of a sudden there were no tracheostomies in house.

Sara Penrod: Yeah. Sometimes we have 20, sometimes we have five, you know, so it was kind of drawn out for that reason. And then at the end, um, I, we had patient, we had clinicians. Um, present their own patients, you know, so it was, that was a lot of the buy-in too, like have them take ownership of it and, and everybody kind of made it their own.

So that was a lot of it. It wasn't, it wasn't something that was just ours. It was ours as a department. So that was a lot of it. 

Dory Forgit: And for the most part, people recognized that they were lacking in depth of skills in this area. Like, like I said, like, sure, I'm comfortable with it, but like, if there's more that I can be offering these patients, then let's do it.

Let's offer them more. Yeah. Yeah. 

Lindsay Griffin: I also think that, um, I, I hear, I hear you, [00:57:00] you talking about how it was really helpful from a departmental level, but I think that it ha the va, the Greenlight tool has value as an individual level too, as an individual SLP, whether that means I'm the only SLP in this acute care hospital, and I'm the one who's faced with deciding.

When to do X, Y, and Z versus, you know what? I can't really get the buy-in of my entire department to do this, but I'm gonna use the appendices to, to note what sort of like the normative values are or what the different event settings mean, or I'm going to use this to sort of guide my own decision making and do the best that I can for the patients, even if my whole department isn't on board with it.

Dory Forgit: Right? Yeah. Mm-hmm. Good point. 

Kate Grandbois: And I, that actually feeds into exactly what I was gonna say just related to the shift that you've explained, is that sometimes that shift starts with ourselves, right? Sometimes it starts with the hard work of thinking about what scares [00:58:00] us, what's giving us, where is the stoplight?

You know, why, why, why am I not moving forward? How can I seek new information? How can I become more competent or confident? Um, and then at some point when you move something new into. Or a team, an organization with other people. I think the other takeaway I'm hearing from you all is that it takes, it takes time, right?

Yeah. It's so much more than throwing an article on someone's desk and be like, Hey, did you see this? And then never talking about it again. You know, it sounds like you all used interactive, you know, interactive case studies and you had dedicated time. Um, you work in an organization that already had some of these expectations, and even with all of that infrastructure, it still took time.

Dory Forgit: Yeah. Mm-hmm. I mean, yeah, we started this in what, 2020? Early 2020. Yeah. So, yeah, and it just got published in April. So all of that thought work, all of that data [00:59:00] collection, all of that analysis, yep. 

Kate Grandbois: I wonder, just in our last couple of minutes, for any SLP who is listening and is interested in the Greenlight tool, or would like to start, you know, think about rolling this out, do you have any advice?

Do you have any considerations or, um, additional pieces of wisdom? 

Dory Forgit: I wanna hear what everyone has to say about this one, but my big takeaway is every trach patient is an individual patient. Don't, please don't lump trach patients altogether. Doesn't matter what it says in the, in the chart, I mean, it matters, but the, the chart alone should not be a reason not to see a patient.

If you have the skills to assess the patient, you should assess the patient.

Sara Penrod: Yeah, I agree. I think the, like, I think what I said earlier, this, the, the idea behind the green light tool is, is empowerment and to, [01:00:00] to take away, um, your barriers and to have the only barriers be really the patient's clinical barriers. And, and to, to, I mean, to really think about what, what you can offer that patient or what the patient needs as a holistic patient and not as a diagnosis, whether that's a trach patient or something else.

Lindsay Griffin: And you don't have to use the green light tool to right, to empower yourself and to gain knowledge. But everybody is busy and rather than doing all of your deep dive research, you could just take this, this beautiful tool that's been created for you. Read it. Then have the knowledge, which will hopefully increase your confidence.

And then, and then like Sarah and Dory were saying, your ability to, um, assess the patient for who they are and not because you're, you're [01:01:00] afraid or unknowledgeable.

Kate Grandbois: I've appreciated this conversation so much. Uh, I think something unique about this conversation is so openly talking about what we're afraid of as clinicians, which I, I don't know, that is openly discussed as often we, you know, disguise it as like, oh, um, it's imposter syndrome, or, uh, oh, I don't, I don't know.

I, I just don't know how to do that. Right. But there are real feelings there, especially when you're working with someone who is. Medically fragile or in an, you know, in an exceptionally vulnerable state. Uh, and I really appreciate the way you all have led this conversation being very patient centered. Um, it's been really wonderful.

Just as a quick few closing statements, um, for anyone who is listening to this episode, who would like to earn Ash, the eu, as I mentioned at the beginning, the link to the post-test is in the show notes. It's also available on our website. A link to this [01:02:00] article as well as many other resources will also be listed in the show notes as well as on our website.

A quick thank you to our team members who helped make this podcast possible. Dr. Anna Pauli, who's our Asha CE administrator and helps with all of our Asha EU processing. Tegan Ahern, our production manager, who wears a million hats and keeps the project alive. Darren Lopez, our production assistant who produces all of our course materials and web production.

Tracy Callahan, our advisory board liaison, who helps make sure we have content expert and content experts involved. And Dr. Mary Beth Schmidt who provides consultation related to our peer review process. And , thank you to our amazing guest today, Dory, Sarah and Lindsay, thank you so much for being here.

This was a really wonderful conversation and I'm very grateful for your time. 

Dory Forgit: Thank you for having us. Thank you. This was fun. Yeah.

Outro

Announcer: Thank you so much for joining us in today's episode, as always, you can use this episode for ASHA CEUs. You can also potentially [01:03:00] use this episode for other credits, depending on the regulations of your governing body. To determine if this episode will count towards professional development in your area of study.

Please check in with your governing bodies or you can go to our website, www.slpnerdcast.com all of the references and information listed throughout the course of the episode will be listed in the show notes. And as always, if you have any questions, please email us at [email protected]

thank you so much for joining us and we hope to welcome you back here again soon.

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