ACQ Vol 10 No 2 2008

Work– l i f e balance : preserv i ng your soul

Data audit Data pertaining to the weekend caseload has been collected since November 2001. This data includes occasions of service (OOS) provided, OOS required but not provided, new referrals, weekend diet upgrades, weekend diet downgrades, number of patients who commenced oral diet or enteral feeding on the weekend, and number of diet changes recommended on Fridays. Data was analysed retrospectively for the initial 10 weeks of the weekend speech pathology service in 2002 and in three subsequent 6-month periods from April 2003 to September 2003, October 2003 to March 2004 and September 2005 to February 2006. The initial 10-week data collected was extra­ polated to provide a 6-month sample consistent with the other time periods recorded. Table 2. Numbers of occasions of service (OOS) and new referrals recorded for selected time periods between November 2001 and February 2006 Nov 2001 – Apr 2003 – Oct 2003 – Sept 2005 – May 2002 a Sept 2003 March 2004 Feb 2006 OOS 270 305 276 235 New referrals 12 72 51 46 a Data for November 2001 to May 2002 was extrapolated from actual data from November 2001 to February 2002. Results Numbers of occasions of service and new referrals recorded between November 2001 and February 2006 are reported in table 2. In the period November 2001 to February 2002, 95% of the OOS were for dysphagia with 5% for speech or lan­ guage difficulties. Four of the six new referrals to the weekend service commenced enteral feeding on the day of review, thus minimising hydration or nutritional complica­ tions as a consequence of their nil by mouth status. During this period 16 patients had their diet consistencies upgraded. A further 14 patients had their diet consistencies downgraded, thereby reducing the risk of aspiration. There was an average of 11 OOS per weekend during each data collection period with no significant increase over time. The number of new referrals increased from 12 in the initial data collection period to 46 in the finale data collection period. Discussion The JHH weekend speech pathology service has successfully provided management of dysphagia, speech and language difficulties to an adult inpatient population within the acute setting for almost six years. This weekend service reduces the number of new referrals received on Mondays and enables clinicians to implement dysphagia management changes on Friday knowing that the patient can be monitored over the weekend. Prior to initiating the weekend service, potential diet upgrade decisions on Friday were often delayed until the following Monday to enable monitoring. This delay could prolong hospitalisation and affect progress in meeting speech pathology, medical and discharge goals. Senior supervision over the weekend is necessary to minimise pressure of time management and increased caseload demands. The ability to refer to the weekend service anecdotally contributes to reduced weekday workload stress among speech pathologists and increased patient satisfaction. The service also manages patients who are suitable for

hours during the week in the department to prevent isolation and allow inclusion in department activities and training (for a total of 0.2 FTE). New graduate clinicians have generally been recruited to the position. The senior speech pathologists within the department provide telephone supervision to the weekend speech pathologist on a rostered basis. The weekend speech pathologist is required to contact the supervising speech pathologist via mobile phone to discuss issues pertaining to prioritisation, critical decision-making and service delivery. The supervising speech pathologist is paid an on-call allowance. Scope of service provision The weekend service is provided to inpatients with swallow­ ing, speech and/or language difficulties. Weekend speech pathology services are not provided to patients with trache­ ostomies or laryngectomies due to difficulties recruiting speech pathologists with competencies in these specialised areas and the time requirements. Patients referred to the weekend service are prioritised according to the schedule set out in table 1. Examples of high priority include new admis­ sions with acute dysphagia or patients who have deteriorated over night. Examples of lower priority include new admissions with acute onset of communication disorders or patients who have improved over night and require review for potential to upgrade their diet. The supervising senior speech pathologist participates in patient prioritisation with the weekend speech pathologist (table 1). Table 1. Current prioritisation criteria Priority Description 1 New admissions to the hospital with acute dysphagia 2 Patients who have deteriorated over night 3 Patients who are nil by mouth without stable enteral feeding 4 Patients at nutritional or dehydration risk due to dys­ phagia 5 Patients commenced on an oral diet that requires review to ensure safety 6 Patients with fluid consistency upgraded on Friday who require review to ensure safety 7 Patients with food consistency upgraded on Friday who require review to ensure safety 8 Patients requiring a direct swallowing therapy program 9 Patients requiring education regarding dysphagia management prior to discharge 10 New admissions to the hospital with acute onset of communication disorders 11 Patients who improve overnight and could be reviewed with respect to an upgrade Inpatients on the current speech pathology caseload who have not been referred to the weekend service by their treating speech pathologist may be subsequently referred to the weekend service by medical, nursing, allied health staff or family and are prioritised according to the prioritisation schedule. The weekend speech pathologist discusses these re-referrals with the supervising clinician prior to seeing the patient. The supervising speech pathologists conduct regular audits of referrals to monitor consistency and appropriateness of referrals across the department.

52

S peech P athology A ustralia