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pandemic to promote quality of life for patients from a CALD background. As COVID-19 was novel, new information developed daily about symptoms, modes of transmission, complications, assessment, intervention and prognosis. This caused a degree of ambiguity in the delivery of SLP care as it stood prior to the pandemic due to limited available knowledge and experience in providing safe and best practice within these unprecedented circumstances. While the core role of SLPs did not change during the pandemic, the many protocols and guidelines surrounding SLP care and hospital wide operations were markedly different and stringent compared to pre-pandemic practice. When compared to the consensus statements and guidelines previously outlined, our practice was largely consistent with recommendations including extensive PPE requirements, cessation of instrumental swallow assessments, delaying tracheostomy cuff deflations until negative test results, modifying routine procedures to reduce aerosol generation, and wearing scrubs/uniforms (Freeman-Sanderson et al., 2021; Zaga et al., 2020). The high-level acuity and rapid influx of COVID-19 patients at our health care service meant SLPs became involved early in their hospital stay to facilitate access and flow, respond to increased service demands and support hospital-wide distribution of clinical skillsets, particularly in AAC and tracheostomy management. A responsive SLP service such as this was described later in the literature, with high importance placed on predicting and contributing to broader workplace planning, preparation and management (Freeman-Sanderson et al., 2021). The experience of S.R.’s case indicates SLPs are able to develop creative adaptations to usual care in novel clinical contexts such as COVID-19, and quickly integrate new and emerging knowledge to enable the provision of best practice. New research has described the significant impact on communication due to COVID-19 PPE requirements; however, other elements of our care including exclusive use of phone interpreters, physical distancing, noisy machines and equipment, as well as the added time pressure in each session posed further challenges in efficiently implementing SLP care that was sensitive to unique linguistic and broader cultural characteristics associated with a particular CALD group (Hamptom et al., 2020; Huang et al., 2019). To address this, the treating clinician implemented strategies such as facilitating telehealth with family members during and after sessions, and trialling various AAC systems translated into Maltese to compliment the use of phone interpreters. The significant barriers to effective, culturally appropriate communication between S.R. and his health care team culminated in confused and distressed behaviour due to communication breakdown. This triggered a paradigm shift in our treatment approach, moving the focus from safety-oriented, conservative tracheostomy management to developing functional communication via the use of AAC and the PMV, and prioritising MDT skill development in using alternative communication methods to support S.R. This notion later became a formalised, SLP led project within our health service aimed at educating staff on the use of various resources to support communication access for people from CALD backgrounds. We found the benefits of promoting communication access were twofold in progressing with intervention goals and also providing opportunities for S.R. to engage in meaningful conversation and participate in traditional customs and activities. Our experience with S.R. reiterates how the values of one

Table 2. Clinical practice modifications and strategies used to support communication access

Education, training and infection containment

the multifactorial causation; however, early testing and rehabilitation as completed in S.R’s care is needed to maximise functional outcomes (Daroische et al., 2021). Discussion The case of S.R. provides an example of SLP management and eventual recovery of a critically ill patient with COVID-19. The case is unique due to challenges of working with a patient from a CALD background within strict and new clinical and health care guidelines, the rapidly changing international health care landscape at the time, and the ability of the SLP to quickly modify practice based on new and limited information on a daily basis. It also highlights the value of the speech-language pathologist’s role during the Use of phone interpreters for every patient interaction Implementation of ward-based telehealth with family members during and after sessions Creating communication opportunities outside of health care language (i.e., telehealth with family in unique locations) Liaison with interpreter services to translate AAC into Maltese Facilitation of rapid upskilling of redeployed ward staff in tracheostomy management Face-to-face contacts reduced to 15 minutes and only critical tasks completed Extensive PPE use (N95 masks, face shields, gowns, gloves) Case history, education and feedback to family occurred via online platforms or telephone 1.5 metre physical distancing, standing to the side of patients Cuff deflation commenced after negative COVID-19 test Strict scheduling and critical decision-making regarding duration and number of cuff deflation trials to reduce exposure risk Conservative progress due to uncertainty of medical stability in unknown virus Delayed application of the PMV to reduce the risk of aerosol generation Tracheostomy Modifying communication environment (i.e., turning off non-essential machines with approval from medical teams) Only essential physical materials brought inside patient’s room Education/training in use of AAC to nursing, medical and allied health staff Completing assessment tasks in small sections across multiple sessions Critical decision-making regarding relative risk vs. clinical significance of oromotor tasks (i.e., volitional cough testing, palate inspection) Conservative use of swallow palpation Use of only minimum oral trials to determine safe recommendations Increased reliance on nursing reports regarding tolerance and delayed SLP review for upgrade of fluid/diet Communication Swallowing Strategies specific to culturally competent care

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JCPSLP Volume 23, Number 3 2021

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