JCPSLP Vol 23 No 3

different states of Australia, further guidelines for service delivery in accordance with state government legislation also became available (Speech Pathology Australia, 2021). Namasivayam-MacDonald and Riquelme (2020) emphasised the important role of the SLP in acute settings, and collated international evidence regarding necessary modifications to clinical practice. Similarly, Zaga et al. (2020) published a literature review to outline classification of aerosol generating procedures, challenges associated with tracheostomy management in COVID-19 patients, considerations for specific patient cohorts, personal protective equipment (PPE) requirements, and potential precautions for some contexts including ceasing instrumental swallow assessments. As the pandemic evolved, later research affirmed the risk of aerosol generation during dysphagia assessment and routine SLP practice, and described the impact of COVID-19 on personal health, safety, and financial security of SLPs (Bolton et al., 2020; Kearney et al., 2021). Additionally, further recommendations specific to workforce preparation and clinical management in the ICU setting have been established (Freeman-Sanderson et al., 2021). The role of SLPs in the management of patients from CALD backgrounds is well established and has evolved as a result of global migration, colonisation and the ageing population (Huang et al., 2019). However, there were little to no guidelines on SLP intervention for patients from CALD backgrounds in the early phase of the pandemic despite the high likelihood of poorer health outcomes as seen with previous outbreaks of infectious diseases (Power et al., 2020). Since then, our profession’s experience with the management of COVID-19 patients has significantly developed, with expert consensus recommendations reiterating the high priority of employing interpreter services for patients from CALD backgrounds to engage in SLP care (Freeman-Sanderson et al., 2021). The aim of this case report is to outline the practical application of the guidelines mentioned above in clinical practice for a patient with COVID-19 resulting in complex swallowing, communication and tracheostomy management. The impact these guidelines have on providing culturally competent care within the inpatient hospital setting is also discussed. This case report outlines some of the challenges associated with the novel coronavirus in this context, and how the limited available information was utilised to guide clinical decision- making. Informed written consent was obtained using a phone interpreter. Patient information S.R. is a 75-year-old Maltese male previously living at home independently who presented to the emergency department (ED) with severe COVID-19 pneumonia. His significant past medical history included hypertension and cardiac disease requiring a pacemaker. S.R. was transferred to the ICU from the ED on day 0 and was ventilator dependent via an endotracheal tube, subsequently requiring a tracheostomy and enteral feeds. Complications of S.R.’s COVID-19 pneumonia included hypoxic brain injury, small subarachnoid and petechial intraparenchymal haemorrhages, and critical illness myopathy. The hospital stay was further complicated by bacterial chest and urinary infections, upper limb deep venous thrombosis (DVT), and failed extubation due to hypoxic respiratory failure. The associated vascular complications of COVID-19 are now well-documented; however, little was known at the time of his admission

Table 1 Timeline of S.R.’s 101 day admission

Emergency department (ED) presentation → Intensive care unit admission (ICU) Intubated, ventilator dependent via endotracheal tube Early supported communication and initial phone contact with family Last positive microscopy culture sensitivities / polymerase chain reaction test Failed extubation due to hypoxic respiratory failure with progressing COVID-19 pneumonia +/– ventilator associated pneumonia Surgical tracheostomy insertion (Size 8 Portex Blue Line Ultra) Ongoing supported communication including alternative and augmentative communication (AAC) such as communication boards, whiteboards, etc. Initial cuff deflation trial with SLP and physiotherapy (PT) Transfer from ICU to acute ward Commencement of brief digital occlusion trials Unarmed violent threat due to communication breakdown (code grey) Continuation of daily cuff deflation trials with SLP and PT Initial application of Passy Muir Valve (PMV 2001 Tracheostomy & Ventilator Swallowing and Speaking Valve) Initial oral therapeutic trials Continuation of SLP and PT led daily cuff deflation trials First blue dye swallow testing and commencement of Puree Diet (Level 4) and Mildly Thick fluids (Level 2) Resolution of dysphonia Upgraded to Soft and Bite Sized Diet (Level 6) and Mildly Thick Fluids (Level 2) Completion of Cognitive Linguistic Quick Test (CLQT) Resolution of dysphagia; commencement of Regular Diet (Level 7) and Thin Fluids (Level 0) Commencement of cognitive communication rehabilitation Initial face-to-face SLP contact

Day 0 28/03/2020

Day 14

Day 17 14/04/2020

Day 18

Day 32

Days 45–47

Day 51

Day 54

Day 60

Day 62

Day 66

Day 67

Day 73

First successful 24-hour cuff deflation

Day 76

Successful tracheostomy decannulation

Days 82–99 Transfer from acute to rehabilitation ward Continuation of cognitive communication rehabilitation Discharge planning with MDT

Day 100 05/07/2020 Day 101 06/07/2020

Resolution of cognitive communication deficits Discharge from SLP services

Discharge to home alone and independent living

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JCPSLP Volume 23, Number 3 2021

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