JCPSLP Vol 20 No 2 July 2018

study. All were female. The number of years of clinical experience with adult inpatients ranged from 3 to 13 years (Table 1) and was similar across groups. All participating SLPs were familiar with the original prioritisation tool but the extent of its use was variable. Prior to participating in the study, the SLPs were given a basic orientation to the redesigned tool in line with what would be typically provided when orientating a new staff member to departmental Table 1. Characteristics of participating SLPs Group 1 (original tool, n = 4) Group 2 (redesigned tool, n = 5) Group 3 (no tool, n = 5)

processes. The study was approved by the health service Human Research Ethics Committee and each clinician provided written informed consent to participate. Procedure Participants were randomised into three groups using a concealed method, with each group asked to prioritise the same hypothetical SLP caseload using one of three approaches: 1. Group 1 (n = 4). Explicit prioritisation using the original SLP prioritisation tool. This tool utilised diagnosis, chronological order of referral, and imminent discharge to allocate patients to one of four priority categories (Table 2). 2. Group 2 (n = 5). Explicit prioritisation using the redesigned SLP prioritisation tool. This tool emphasised clinical needs and risks, the last intervention provided to the patient, and the planned discharge date to allocate patients to one of three categories (“Prioritised work”, “Standard work”, and “Not for this service”) (Table 2). 3. Group 3 (n = 5). Implicit prioritisation using clinical judgement without the guidance of a prioritisation tool. Each clinician was provided with the same written clinical activity consisting of 45 hypothetical scenarios, organised into five independent “days” with nine referrals per day. Each scenario was developed by a SLP manager (greater than 15 years of clinical practice), and was based on typical

Primary work area Acute only Continuing care only Both acute/ continuing care Level of clinical experience with adults (years) Range Median

1 1

1 2

3 0

2

2

2

3–12 9.5

5–13 10

4–11 10

Table 2. Comparison of key features of the original and redesigned SLP prioritisation tools

Original tool

Redesigned tool

Prioritised work Response time: Same day Examples: • Intervention to facilitate safe discharge < 48hrs • High risk of complications or deterioration of function without intervention • Initial contact with new patients • <50% of desired therapy over previous 5 days Standard work No specified response time Examples: • Patients with significant difficulty participating in health care without SLP intervention • Intervention required to manage concern around communication, cognition or dysphagia • Patients discharge date unknown or flagged for >48hrs and intervention/discharge planning required • Low risk of complications, consequences and or deterioration of function/ participation without intervention

Highest priority

Category 1: Immediate risk Response time: ≤ 24 hours Examples:

• Aspiration risk, no dysphagia management plan • Intervention to facilitate safe discharge < 24hrs • Head and neck surgical patients requiring assessment for oral intake • Tracheostomy patients requiring cuff deflation Category 2: Recent events and improved outcomes through intervention Response time: ≤ 2 days Examples: • Recent reduction in communicative capacity affecting function • Recent change in swallowing status requiring review of dysphagia management plan • Education to facilitate safe discharge > 24hrs • Communication assessment for tracheostomy patients Category 3: Chronic condition/acute condition with limited improvement likely/improve quality of life/low risk acute condition Response time: ≤ 5 days Examples: • Recent changes to communicative function but reduced motivation for intervention or not significantly affecting participation • Swallowing difficulties with existing dysphagia management plan but potential for improvement Category 4: Existing conditions Appropriateness of referral discussed with referee Examples: • Patients who have a discharge plan and are eligible for other SLP service/s • Longstanding communicative impairment seeking social communication support

Not for this setting Examples:

• Patient declined SLP intervention on several occasions and considered “competent” to be involved in health care decisions • Patient at premorbid level and improvement unlikely • Patient from other heal t h service/nursing home and has current management plan

Lowest priority

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JCPSLP Volume 20, Number 2 2018

Journal of Clinical Practice in Speech-Language Pathology