JCPSLP Vol 20 No 2 July 2018

and swallowing, there is potential for specialist clinical services to be involved in medication administration and even medication prescribing. One such context is SLP led nasendoscopy, which could involve the role of SLPs independently administering a topical anaesthetic. When completed by an ear nose and throat (ENT) specialist, nasendoscopy frequently includes the ordering and administration of topical anaesthetic and decongestant such as Co-Phenylcaine Forte, which is sprayed nasally to provide anaesthesia and improve both patient comfort and image quality through vasoconstriction (Douglas, Hawke, & Wormald, 2006). Although other medications – e.g., lidocaine – can be used during an endoscopy procedure to improve patient comfort, research has supported improved ease of passage of the endoscope and superior views with Co-Phenylcaine Forte use (Douglas et al., 2006). In contrast to assessments conducted by an ENT, when nasendosocpy is performed independantly by a trained SLP, the SLP is unable to provide a topical anaesthetic/ decongestant during the assessment. In this context, either the assessment proceeds without any anaesthesia/ decongestant, or the clinician requires a medical officer to provide the spray prior to the assessment. Such models reduce the efficiency of service delivery and fail to address the issue of patient comfort during the procedure. Therefore, this prospective cohort study presents pilot data on the patient safety and clinician perceptions of SLP led administration of Co-Phenylcaine Forte nasal spray, administered for the purposes of independent nasendoscopy in the assessment of patients with voice and swallowing problems. In addition, the study provides an overview of the legislative, training and credentialling process required to implement SLP led medication administration of Co-Phenylcaine Forte nasal spray in the current service. Although it is acknowledged that the processes described are specific to the local context, the current paper provides an example of the potential processes and steps required to safely implement medication administration. Method Clinical context The need for SLP led medication administration was identified in the Speech Language Pathology Allied Health Professional (SLP AHP) led dysphagia and dysphonia service, within the Integrated Specialist Ear Nose and Throat service at a metropolitan Queensland Hospital. The evaluation of the SLP AHP service is outlined in a prior publication (Seabrook, Schwarz, Ward, & Whitfield, 2017). The clinic provides independent SLP management for patients referred to the ENT specialist for dysphagia and or dysphonia who are considered by the ENT consultant to be a Category 2 or Category 3 (low to medium priority) patient. All patients attending the SLP AHP ENT service undergo an initial independent assessment by a trained and credentialed SLP including a comprehensive case history, a clinical assessment of voice and/or swallowing, and an instrumental assessment of their voice and/or swallowing function, either with nasendoscopy (FNE) and/or fibreoptic endoscopic evaluation of swallowing (FEES). As per the Therapeutic Goods Act (1989) and Poisons Standard (2017) Co-Phenylcaine Forte nasal spray is a Schedule 2 drug, hence administration by a SLP without credentialing is not permitted. Therefore within this clinical model, Co-Phenylcaine Forte nasal spray is ordered and administered by a medical officer to improve patient comfort and visibility for both FNE and FEES. This

creates service inefficiency as the SLP requires the presence of a medical officer at time of assessment. Co-Phenylcaine Forte nasal spray was the chosen medication to be trialled in this service due to evidence of its superior benefits to other similar medications during endoscopy (Douglas et al., 2006) as well as its pre-existing use within the facility and local medical officer preference. Service establishment To obtain the legal right to independently administer the Co-Phenylcaine Forte nasal spray within this clinical model, in Queensland, Australia, a number of levels of permissions/ approvals, training and credentialing, as well as risk mitigation processes were required. These are outlined in Figure 1 and involve both local site and state legislative processes. In addition, training required a number of modules (information found in the appendix) and a formal competency sign off which can be seen in Table 1. Exact steps within this process would vary depending on the health facility policies and state laws; however, the process will involve multiple phases and can require considerable time investment to achieve permissions. Participants Two clinicians working in the SLP AHP clinic were credentialed to complete independent administration of Co-Phenylcaine Forte nasal spray. Both clinicians had over 8 years experience as a practising SLP and held either an advanced or senior level position within the service. Both clinicians had previously completed local competency to independently conduct nasendoscopic assessments and were credentialed by the local hospital and health service. The clinicians then participated in the collection of pilot data on 100 consecutive patients seen by the SLP AHP service between April 2016 and October 2017. In this pilot trial, specific patient demographics were not collected for the 100 participants. However, demographics of a cohort of 158 patients attending the SLP AHP ENT services for a time period immediately prior to this trial has been reported elsewhere (see Seabrook et al., 2017) and it is assumed the current cohort would be similar in nature. Procedure For all patients referred to the service, a comprehensive medication case history was collected by the SLP to screen for precautions and contraindications as per Table 2. Then if the patient was deemed suitable, Co-Phenylcaine Forte nasal spray was administered and patient status was visually monitored immediately post administration and throughout the session. Following the session the clinician recorded: (a) if Co-Phenylcaine Forte nasal spray was or was not administered, and the reasons why administration did not occur; (b) the number of administrations completed, as well as (c) type, severity and outcome of any adverse reactions, where an adverse reaction was defined as any change in medical status observed by the SLP and/or the patient reporting any discomfort or distress (including any known common side effects of the medication such as anxiety, dizziness, nausea, vomiting and disorientation) following administration. Immediately after each session the SLP also completed a confidence rating regarding conducting medication administration with each patient, using a 5-point Likert-like scale (1 = very confident , 5 = completely lacking in confidence ). Data was collected at the time of the appointment, and later entered onto a Microsoft Excel spreadsheet. Data was analysed using descriptive statistics computed using Microsoft Excel. The study was conducted with ethical clearance (HREC/16/QPAH/182).

Anne Coccetti (top) and Bernard C. S. Whitfield

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JCPSLP Volume 20, Number 2 2018

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