Rising to the challenge: the speech and language therapy profession responds to COVID-19 - RCSLT
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THE OFFICIAL MAGAZINE OF THE ROYAL COLLEGE
OF SPEECH & LANGUAGE THERAPISTS
May 2020 | www.rcslt.org
Swallowing Awareness
Day: 2020 round-up
¬
Introducing the
new ‘Research and
Outcomes Forum’
Rising to the challenge: the speech and language
therapy profession responds to COVID-19
01_Cover_Bulletin May 2020_Bulletin 1 30/04/2020 12:39
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Contents ISSUE 817
4 Letters
5 The SLT COVID-19 response
29 7 Opinion by Caz Barnett and
Lorna O’Kane
8 Pauline Downie shares her
trust’s response to the start
of the COVID-19 outbreak
7 12 Dr Sally Archer and
Claire Twinn on building and
sustaining a COVID-19 response
12 16 Swallowing Awareness Day
2020
20 Research and Outcomes
Forum
23 In the Journals
25 Jois Stansfield:
RCSLT 75th anniversary
16 27 Obituary
29 My working life:
Scarlett Tozer-Milne
8
CONTACTS
President: Nick Hewer PUBLISHING DIRECTOR
ROYAL COLLEGE OF SPEECH AND Honorary life vice president: Joanna Marsh
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Email: bulletin@rcslt.org Chair: Dr Della Money Buxton Press 020 7880 6200
Website: www.rcslt.org Deputy chair: Mary Heritage www.redactive.co.uk
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Tel: 020 7324 2777 ©2020 Bulletin is the monthly magazine of
the Royal College of Speech and Language
Email: rcsltjobs@redactive.co.uk
EDITORIAL Therapists. The views expressed in the
Editor: Victoria Briggs Display sales: Bulletin are not necessarily the views of
Tel: 020 7880 7668 the RCSLT. Publication does not imply
Deputy editor: Amelia Dale endorsement. Publication of advertisements
Email: bulletin@redactive.co.uk
Contributing editors: Amit Kulkarni, in the Bulletin is not an endorsement of the
Katie Chadd advertiser or of the products and services.
The publisher reserves the right to alter
Content assistant: Siobhan Lewis COVER ILLUSTRATION or withdraw any advertisement without
Art editor: Yvey Bailey Cat Finnie consultation.
May 2020 | www.rcslt.org Bulletin 3
03_Contents_Bulletin May 2020_Bulletin 3 30/04/2020 12:39
Bulletin thrives on your letters
Victoria MY
WORKING
and emails. Write to the editor,
RCSLT, 2 White Hart Yard, London
SE1 1NX. Email: bulletin@rcslt.org
Briggs LETTERS Please include your postal address and
LIFE telephone number. Letters may be edited
for publication (250 words maximum).
EDITORIAL
Bulletin’s
Seismic shifts youngest
C reader
hange, even of the moderate kind, can feel disruptive
and disorienting. When change arrives suddenly,
is global in nature, and possesses such profound As a proud SLT to one-
consequences for the health and wellbeing of millions, then year-old baby girl Alaya
those feelings—greatly amplified—can become overwhelming. (pictured), I thought I would
Since social distancing measures were implemented in share a photo of her holding
March, it has been work—carried out remotely, facilitated by February’s Bulletin. She has
technology—that has provided us with reference points and the been dragging the magazine
comfort of routines: the familiar production cycle of a monthly around with her ever since
publication; the contact with members whose contributions we received it. She loves the
make Bulletin the magazine it is. cover, and naturally I used it
We know that, for many of you, the world as you knew it as an opportunity to provide
has shifted beneath your feet. That might be because you’ve some language stimulation!
been redeployed to the frontline of the COVID-19 response, or Thanks for this.
you’ve had to radically rethink how to deliver therapy to service Yaksha Makan, SLT
users you’re unable to see in person. For some, the pandemic
has brought job insecurity and financial concerns. For many
Anniversary
reflections
of our #SLT2bs, study programmes have been disrupted and
placements cut short. And then there is the coronavirus itself,
and the resulting safety concerns many of you have around
personal protective equipment (PPE). This anniversary year gives
In the last few weeks, the RCSLT has been working around the opportunity to reflect on the early
clock to address your concerns. On p6, Kamini and Della share growth of our profession, and I am
an overview of the efforts being made to influence at the highest reminded of some of the unusual
levels in support of members, and to draft new guidance that accommodation issues of the
aims to keep you, your families and service users safe. 1950s and 60s.
Our communication with you has also been subject to some After qualifying, my post included
changes. The situation brought about by the pandemic has been setting up the speech therapy service
so fast-moving that we’ve placed a greater focus on digital in two hospitals! I recall being given
communications: we built a COVID-19 hub on the website unsuitable accommodation within
(www.rcslt.org/learning/covid-19) that we’re adding to daily, a hospital for the elderly—totally
and implemented a more frequent enewsletter schedule to keep unsuitable for treating children—
you abreast of developments far quicker than is possible in print. and so service was suspended and
As such, we’ve had to deviate a little from the standard Bulletin ultimately resumed in the maternity hospital.
format this issue. You will notice that the news pages have been Joining school health services produced unlikely challenges:
scaled back (news brought to you in a monthly publication is one school expected me to treat in my car; at another I was
at least four weeks old by the time it drops through doors), and assigned the cloakroom (with that obnoxious smell of drying
we’ve pushed back the magazine production schedule by a coats, and curious pupils en route to the toilets!). A village school
couple of weeks, too. proved a greater challenge—we had the head teacher’s house,
Other changes concern the content. This issue, we’re grateful across the road and down a muddy lane. Then there was the school
to Pauline Downie, the RCSLT’s Scotland representative, for where I was assigned the staff room, filled with staff members on
sharing NHS Lanarkshire’s insights and response to the early their breaks, making therapy impossible.
days of the pandemic (see p8). And to Dr Sally Archer and Claire Unsurprisingly I soon found clinic accommodation for children
Twinn from Guy’s and St Thomas’ NHS Foundation Trust, who to be brought to me! I also arranged joint meetings with teachers
sent us an account of their department’s heroic efforts to ready to establish mutual understanding. We were, after all, a relatively
themselves for the coronavirus impact (see p12). new profession.
Bulletin will be back with you next month. Do keep sending Thirty years later, I was invited to meet HRH Princess Anne
us your submissions in the meantime, and keep an eye on our when she opened the new rehabilitation building at one of the
website and social media channels. New guidance, resources, very hospitals where I set up the speech therapy service so many
updates and announcements will be posted there first. years ago.
Barbara Hull, retired SLT manager, Oxfordshire
Victoria Briggs,
editor
bulletin@rcslt.org FOLLOW THE RCSLT ON AND
@rcslt_bulletin VISIT: WWW.RCSLT.ORG AND FOLLOW THE LINKS
4 Bulletin May 2020 | www.rcslt.org
04_Editors Lette_Bulletin May 2020_Bulletin 4 30/04/2020 12:40
News
The SLT COVID-19 response
At RCSLT HQ, we've been inspired by the their care pathways. “COVID-19 has seen
way the speech and language therapy our service provision challenged like never
before, but the one tool that gives hope for
profession has risen to the significant
continuing qualitative patient-centred care
challenges brought about by the pandemic. is technology,” Kathy says. Pictured: Emma
Social media has been awash with SLTs Hodgson at Bishop Auckland Stroke Unit.
sharing incredible images and messages of
support, creating resources, and offering 3. Head and neck SLT Sarah Harris gears
their skills and services wherever they've up for her ENT clinic (@LPTAdultSpeech
been needed most. @SarahHa55171110).
Here are just a handful of photos that
4. SLTs at Imperial College Healthcare NHS
show how members (and their families) Trust have fit tested PPE masks for over 500
have been adapting to new ways of working. staff. Pictured: Justin Roe and Zasha Mauger
practising their technique.
1. Three-year-old Jenny Cronin fits her
surgical mask before treating some patients 5. SLT Steph Burgess (@StephFBurgess)
at home (@DrCiaraOToole). from the Airedale NHS Stammering Project
showcases the use of telemedicine: “I’ve been
2. Kathy Cann (@KathyCann1) and the SLTs using telemedicine for therapy sessions for
at Country Durham and Darlington NHS Trust many years now, but it feels as though it’s
have started integrating technology into finally come into its own,” she says. 1
2
3
4 5
May 2020 | www.rcslt.org Bulletin 5
05_Covid Members_Bulletin May 2020_Bulletin 5 30/04/2020 12:41
DELLA
MARIAMONEY
LUSCOMBE
LUSCO
SCO
OMBE
& KAMINI
& KAMINI
GADHOK
GA
GADHOK RACHEL PURKETT
FULL IMPACT Stronger links
For me, and many others I suspect, crisis has
brought with it a steep learning curve.
In just a few weeks, I’ve learned a lot of new
terminology, words I’d never needed before:
aerosol generating procedures, viral shedding,
fluid-repellent surgical face mask. Concepts
previously unknown to me have become critical to
the profession, matters of life and death.
I’ve also learned a bit more about my friends
and colleagues, by seeing them under new
pressures and in different environments, as
videoconferencing transports me into their homes.
I suspect that when this is over, we’ll be left with
‘Unprecedented’ must be a contender stronger links and better ways of working.
for the word of the year. Indeed, “...we continue to But the learning that impresses me most? It’s the
nothing else quite describes the
position we all now find ourselves in.
pull together as insight I’ve had into the character of the speech
and language therapy profession.
At the time of writing, in early a profession” When our lives suddenly transformed in March,
April, the Prime Minister has been one of the projects I had to put on hold at work was
admitted into intensive care. a survey of RCSLT members.
While we have yet to understand In common with other professional associations,
the full impact of the coronavirus Allied Health Professions Federation we conduct one of these every year or two, with
outbreak, what we do know is that to lobby and ensure our collective the aim of understanding what your values are,
the country and the world will not be voice is heard. what makes you tick, and what the RCSLT can do to
the same after it has passed. We would like to thank all the SLTs support the profession.
For us, what is critical is that, who have been involved and given The survey will go ahead when life is more
throughout this crisis, we continue to their time and expertise. normal, but in the meantime, your actions in crisis
pull together as a profession. As a result of the lockdown, have told me a few things about you. Here are
We have been impressed and many of the events and services we my takeaways:
grateful for the strong leadership that would normally provide have been
the profession has demonstrated, disrupted, and so we are pleased 1. You are fast. At the first sign of need, SLTs came
rising to the challenge and using its that we can use the full breadth of together, working at a pace we didn’t previously
expertise and skills wherever communications to engage you, our think was possible, to develop guidance that would
they’ve been needed most, from members, including more frequent keep members safe and keep them in work caring
playing our part in new developments newsletters and social media posts. for patients.
such as Operation Nightingale, to While we have had to cancel
maintaining a wide-range of other the RCSLT study day and awards 2. You are innovative. When social distancing rules
priority services. ceremony this year, we are looking came in, SLTs rapidly came up with new ways to do
The RCSLT has been working ahead to what we know will be a their work safely, bringing in telehealth at a rate of
alongside members to help respond period of rebuilding in the months to knots to ensure service users wouldn’t be let down.
to the challenges. Together we have come. An important part of that will
developed guidance, shared training be celebrating our achievements, and 3. You are a community. SLTs have taken to social
resources, and built our networks we are thinking about how we can media like never before throughout the crisis,
and resilience. use the RCSLT Honours and Giving sharing what they are doing, asking for advice and
We have also worked together Voice awards to do this. Please look shoring each other up through difficult times.
to influence on behalf of SLTs and out for details.
service users, informing government We hope that you are all keeping I know as SLTs you’re always reflecting on your
guidance on PPE, developing the role safe. Please do keep engaging with us, practice, and on life. Do let me know what you’ve
of SLTs as part of the multidisciplinary raising issues that are of concern and learned about the profession and about yourself.
team caring for COVID-19 patients, sharing your achievements. Tweet @RCSLT
ensuring continuity of services for
other groups, and securing the future Dr Della Money, RCSLT chair
education and training of students. Kamini Gadhok, MBE, RCSLT Rachel Purkett, RCSLT director of engagement
Through it all, we have worked in chief executive and communications
partnership with colleagues from the Email: kamini.gadhok@rcslt.org Email: rachel.purkett@rcslt.org
6 Bulletin May 2020 | www.rcslt.org
06_Columns_Bulletin May 2020_Bulletin 6 30/04/2020 12:41
COLUMN
& O’Kane Opinion
Caz Lorna
Barnett
Caz Barnett and Lorna O’Kane ask: why aren’t we collected data that found that, on lack of clinical guidelines and the
talking about functional neurological disorder? average, one patient with fact that FND was not mentioned
functional neurological on any pre-qualification courses.
symptoms was referred to speech However, all SLTs who were
and language therapy each week. interviewed believe we have a role
Despite the fact that SLTs come in caring for patients with FND.
across these patients regularly, A multidisciplinary group is
there is no mention of FND in the currently developing consensus
RCSLT’s clinical guidelines, and guidelines for speech and language
very limited literature exists on therapy. Given that patients with
the topic. So why aren’t we, as a FND are being referred to us and
profession, talking about it? we are listed as core members of
One reason may be that there the multidisciplinary team, we
is a huge variety of terminology believe it is time for SLTs to start
surrounding the diagnosis, talking about FND in order to
for example: ‘psychogenic’, identify gaps in current evidence
‘conversion disorder’, ‘medically and practice, improve consistency
Opening the unexplained symptoms’,
‘dissociative disorder’, etc. This
in our management and ultimately
improve outcomes of patients
conversation
wide variety of diagnostic labels who present with functional
can create inconsistencies in both neurological speech, language or
clinical and research practice. swallowing symptoms. ■
The use of the term ‘functional’
has been favoured over previous Caz Barnett, SLT, University
labels in recent years because Hospitals Birmingham NHS
it represents a biopsychosocial Foundation Trust and committee
model of aetiology rather than member of UK Functional
assuming a psychological Neurological Forum
aetiology, which previous labels Email: caroline.barnett@
such as ‘psychogenic’ suggested. heartofengland.nhs.uk
Lorna O’Kane, SLT, The National
Hospital for Neurology and
“It is time for SLTs Neurosurgery in London
to start talking Email: l.o’kane@nhs.net
about FND…” For further information, visit
www.fnforum.org
References
Speech, language and
American Psychiatric Association.
swallowing symptoms are
Diagnostic and Statistical Manual of
common in FND (Barnett et Mental Disorders. 5th edition. Arlington:
al., 2019). Despite this, there American Psychiatric Publishing, 2013.
is a lack of literature specific to Barnett C, Armes J and Smith C. Speech,
speech and language therapy language and swallowing impairments in
functional neurological disorder: a
and FND. However, SLTs are scoping review. International Journal of
ILLUSTRATION BY Sara Gelfgren still listed as core members Language & Communication Disorders
of the multidisciplinary team 2019; 54, 309-320.
for the care of patients with Gargalas S, Weeks R, Khan-Bourne N,
Shotbolt P, Simblett S, Ashraf L, Doyle C,
FND (Healthcare Improvement
Bancroft V and David A. Incidence and
F
unctional neurological (American Psychiatric Scotland, 2012). Caz Barnett outcome of functional stroke mimics
disorder (FND) is when Association, 2013). FND is recently interviewed SLTs with admitted to a hyperacute stroke unit.
patients present with common across healthcare experience of working on stroke Journal of Neurology, Neurosurgery and
Psychiatry 2017; 88, 2-6.
motor or sensory settings, and functional stroke units; all those interviewed
Healthcare Improvement Scotland (2012)
symptoms that would usually be mimics comprise up to 8.4% of reported that they are regularly Stepped Care for Functional Neurological
under their control (such as admissions to stroke units involved in the care of patients Symptoms. A New Approach to Improving
talking or swallowing) in a way (Gargalas et al., 2017). The with FND. Challenges were cited Outcomes for a Common Neurological
Problem in Scotland: Report and
that is discordant with known hyper-acute stroke unit at when it came to managing this
Recommendations. Available from:
neurological conditions Birmingham Heartlands Hospital patient group, namely due to the bit.ly/2JIb6H9 (accessed 6 April 2020).
May 2020 | www.rcslt.org Bulletin 7
07_Opinion_Bulletin May 2020_Bulletin 7 30/04/2020 12:42
FEATURE
COVID-19
Be calm. Stay wise.
Be kind
Pauline Downie shares the response of NHS
Lanarkshire’s speech and language therapy
service to the start of the COVID-19 outbreak
ILLUSTRATION BY Cat Finnie
B
y mid-March, NHS ■ On Monday 16 March, we were advised key workers was advised to stay at home
Lanarkshire speech to cancel all non-essential meetings and (apart from to undertake food shopping and
and language therapy training. other essential activities).
service had received ■ On Wednesday 18 March, we were told As head of speech and language therapy,
its first referral of a to cancel all routine patient activity and an my role in this situation has been to provide
patient with suspected announcement was made that schools were leadership and co-ordination, to look
coronavirus, and our to close on Friday of the same week. after staff wellbeing, and to provide clear
first member of staff ■ By Thursday 19 March, a decision was communication to staff, stakeholders and,
was also off with symptoms. made to use some of our clinic rooms as via line management structures, to the AHP
Since then, we have been working Community Assessment Hubs. SLT staff spent director and into the command structure.
at speed to make the service changes Wednesday to Friday retrieving records and At the time of writing on Thursday
necessary to combat the spread of IT equipment from schools, and clearing 26 March, all routine management functions
COVID-19, and to ensure all NHS staff and out the clinic rooms. At the same time, we have been suspended: we are only dealing
resources are used to best effect. To give started carrying out clinical triage so that we with issues around staff pay or absence.
you an idea of the pace of change, I have could focus on high-risk patients and clients. All our energy is going into caring for our
documented how the next few days in ■ On Monday 23 March, the government high-risk patients and preparing our staff to
March played out: announced a lockdown and everyone except move to new roles. ↘
8 Bulletin May 2020 | www.rcslt.org
08-11_Cover feat_Bulletin May 2020_Bulletin 8 30/04/2020 13:51
FEATURE
COVID-19
May 2020 | www.rcslt.org Bulletin 9
08-11_Cover feat_Bulletin May 2020_Bulletin 9 30/04/2020 13:51
FEATURE
COVID-19
Leadership
It was clear from the outset that our current
team and leadership structure would need “Every single person is
to change in response to COVID-19. Each
service already had a business continuity
plan and a pandemic flu plan in place,
playing a vital part”
but due to the severity and speed of this
pandemic, it was clear that a radical
restructure would be required.
In normal times, our structure comprises
an adult service with three general hospitals
and community services; the children and
young people’s service with 10 locality
teams and a specialist pre-5 complex needs
team; and a small board-wide adult learning
disability team.
On Friday 13 March, we started holding
a daily speech and language therapy
teleconference with our usual leadership
team. By Monday we had pulled in other
leads as back-up in case we were ill, as
well as our union representative, to help
with issues regarding staff mobilisation in to help with the wider NHS response to 24-hour helpline. It has now been expanded
particular. I am also taking part in a daily COVID-19. Everyone was asked to volunteer to include staff from the psychological
AHP conference call, and our AHP group is for other roles and their response has been service, SLTs and other AHP staff. This
linked to strategic command via our amazing—every single person is playing a service will be very much needed by all of
AHP director. vital part. us working in the NHS. Many of our SLT
Our new structure is now three teams For the duration of the crisis, their new staff are trained counsellors already or have
(critical care, SLTs mobilised to the wider NHS roles will be: excellent counselling skills. They have also
workforce, and the working from home team) had training in trauma and possess excellent
with oversight from the SLT critical leadership Health care support worker communication skills when it comes to
team, including the head of service, team Staff in this role are currently preparing helping people in distress. Training is being
leads and administrative support. themselves to be on the frontline of patient provided wherever it is needed.
care. As well as completing some hastily
Critical care arranged training, they are also busy Wellbeing
This involves everyone currently providing making childcare plans, organising cover Our wonderful psychological service
speech and language therapy to urgent/ for other caring duties, and building their colleagues have produced guidance for staff
high-risk adults, children and adults with network of support for the months ahead. on coping with the coronavirus, which was
a learning disability—either directly in our A small group of our staff are already shared by one of our other health boards in
hospitals, or remotely through the ‘Near Me’ health care support workers (HCSWs) or Scotland. Here in the speech and language
video consultation service. I have asked my have specific skills such as phlebotomy, therapy service we have adopted the mantra
adult team lead to temporarily oversee the or experience working as a NHS 24 call ‘Be calm. Stay wise. Be kind.' (from the
clinical leadership of this team, particularly handler. They will be able to work wherever organisation Action for Happiness:
around clinical decision-making, safety, their skills are most needed in the www.actionforhappiness.org). Our staff
infection control and the use of personal COVID-19 response. care and wellbeing team is there for us, and
protective equipment (PPE). Many other AHPS will take on the role of soon our staff will be part of that team.
We have been advised by ear, nose HCSW. In the interim period, many of them In my daily updates to staff, I have started
and throat (ENT) colleagues to cease are also taking on these duties: to share information about my network of
any nasendoscopy or valve changing ■ Patient care; ie the provision of personal support and this has resulted in colleagues
procedures. So far, we have not seen any care for patients in our hospitals. sharing their funny stories with me, too. One
patients in the community directly as we ■ Domestic services: these staff will be of them has now started a blog, which is very
have been able to meet their needs through working in challenging conditions, perhaps private and offline, and the humour in that
Near Me. These are also our most vulnerable using unfamiliar PPE and following Control is helping most of us through. It is incredible
patients and are self-isolating at home. of Substances Hazardous to Health (COSHH) how humour can be used to support others,
guidance. They will be on the frontline too, even in a situation such as this.
SLTs mobilised and will be vital to ensuring the hospital We have expanded our team
This involves all staff in the speech and environment is clean and safe. communication to include stories from the
language therapy service: SLTs, SLTAs and frontline, and to hear about the experience
administrative staff (approximately Staff support of staff working in other jobs, as well as from
70 individuals who usually carry out routine This service is usually staffed by our spiritual home. There is no pressure to contribute or
functions). They will be taking on new roles care and wellbeing colleagues and has a read these, as we realise that some people
10 Bulletin May 2020 | www.rcslt.org
08-11_Cover feat_Bulletin May 2020_Bulletin 10 30/04/2020 13:52FEATURE
COVID-19
are in a different headspace. But we hope in This team will also start to look at recovery I have been trying to make my own
doing this that it will help to relieve some of the speech and language therapy service communication as clear as possible. As well
staff anxieties and uncertainties, and that once this unprecedented situation is over. as taking part in daily teleconferences with
it will help us to stay together as an SLT AHP and SLT leadership, I am writing a
family—until we can all be together again. Communication daily update for our staff as part of the NHS
We plan to keep in light touch with As SLTs, we are naturally thinking about Lanarkshire daily briefing. This is also part
speech and language therapy staff as their what this situation is like for our service of caring for the wellbeing of our staff—in
focus has to be on their new roles and users. What is it like for parents trying to this time of uncertainty, they too share
teams, but we want them to know they are explain to their children the need for hand the same worries of everyone else in this
still ‘ours’. When we have come through washing, physical distancing, or why they country, as well as those that come with an
this, all of them will be coming back to us— cannot visit their grandparents? NHS role.
certainly with new skills but also, possibly, What is it like for people with I am sure a lot of speech and language
needing support. communication difficulties trying to therapy services are having similar
understand all the information they are experiences to us. And while we haven’t
The working from home team being told about what to do if they become got it all sorted yet, and are certainly not
Our third and by no means final team is unwell? How are they handling being tested calm all of the time, I do hope we continue
made up of staff from all care groups within and treated by people who are (quite rightly) to remain wise and kind. We have all had
our service who MUST stay safe at home wearing masks? How is someone with our tears and wobbles these last few weeks,
for medical reasons. Their function is to comprehension difficulties, or someone who and I am sure there are more to come, but
assist with staff mobilisation and to support relies on lip reading, going to cope? everyone is pulling together and supporting
the critical speech and language therapy And what is it like for people in our one another so that we can give the best
clinical and leadership teams. These staff hospitals who are ill and dying and trying to help to the people who need us. ■
have compiled a list of our IT resources, express their fears and love to their families?
(eg tablets and laptops) and are organising I have seen an amazing amount of
remote access for anyone who needs it. communication supports being shared by
Once staff are mobilised, the working from SLTs and others all around the world in an Pauline Downie, head of speech and
home team, with the leadership team, will attempt to help people with communication language therapy, NHS Lanarkshire;
be responsible for supporting the SLT critical problems in this situation. chair of the Scottish SLT managers
leadership and clinical functions. They will I also know that the RCSLT is collating and leaders network; RCSLT Country
also support people who are in crisis due resources to help with this as well as Representative – Scotland
to their communication needs, and where generate professional guidance in Email:
our intervention can reduce impact for that response to COVID-19 (www.rcslt.org/ Pauline.Downie@lanarkshire.scot.nhs.uk
person, their family and on other services. learning/covid-19). @paulinedownie
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May 2020 | www.rcslt.org Bulletin 11
08-11_Cover feat_Bulletin May 2020_Bulletin 11 30/04/2020 13:52FEATURE
COVID-19
When a sprint
becomes a marathon
Dr Sally Archer and Claire Twinn on the race
to build and sustain the COVID-19 response at
Guy’s and St Thomas’ NHS Foundation Trust
ILLUSTRATIONS BY Louise French
I
t seems like a lifetime ago that Now, at the end of a week in which we or virtual appointments using specific
our trust put out a statement on have reached a milestone at St Thomas’, online software. This is a completely
its social media platforms that it where all of our adult inpatient referrals to new way of working and not without its
was treating its first patient with SLT were COVID-19-positive or suspected of challenges, both technical and clinical;
coronavirus. It reassured the public being so, we have taken stock of how far we it has taken a huge amount of work to
that all of our services remained have come and what it has taken to get here. implement this change so quickly and
open as usual. That was on efficiently. Partnerships between clinical
6 February, and, since then, the hospital Moving mountains and administrative staff have been key, with
and our ways of working have changed The trust has moved mountains to increase the admin team being integral to ensure
almost beyond recognition. capacity and meet the challenge presented the correct coding of appointments, as well
We work at Guy’s and St Thomas’ NHS by coronavirus; the speech and language as dealing with huge volumes of telephone
Foundation Trust in central London; at therapy department has been working flat out queries from patients.
the time of writing (early April), London on this cause, too. Our outpatient services, Our inpatient service has been subject
reportedly has almost double the number as well as voice, cancer and general, have to significant change on a daily, if not
of cases of COVID-19 than any other completely transformed—an enormous piece hourly, basis. Not only have we seen many
part of the UK, and our local boroughs of work involving careful clinical triaging and new wards opening, we have also seen a
of Lambeth and Southwark have been the development of robust systems and risk dramatic increase in the number of critical
hit hard (www.gov.uk). Having been an assessments to ensure that all patients are care beds, with plans for more discussed
early high consequence infectious disease accounted for and managed safely. daily. Patients with COVID-19 or suspected
centre (HCID) with a large critical care All outpatient appointments in the COVID-19 are being cohorted within
department, it is unsurprising that the voice service, and the majority of our dedicated wards and we have had to flex
number of patients with the virus at our cancer and general outpatient services, our usual speech and language therapy
trust has increased rapidly. have been converted to either telephone ward allocation accordingly. This means a
12 Bulletin May 2020 | www.rcslt.org
12-14_Feature2 A_Bulletin May 2020_Bulletin 12 30/04/2020 13:55FEATURE
COVID-19
“PPE takes its toll.
guidelines in line with RCSLT advice (see:
bit.ly/RCSLTCovidGuidance), but building
close working relationships with ward staff
Wearing it is exhausting…”
has still been central to avoid resistance in
response to our requests.
Keeping on top of the changes in guidelines
and the availability of types of PPE has been a
daily task and a source of anxiety in the team.
Having weekly huddles to openly discuss our
worries, review the guidelines and videos, and
significant change for all therapists, with advice provided by the RCSLT and our practise ‘donning and doffing’ has helped.
many working in unfamiliar areas as trust guidance on what constituted an Having a named infection control SLT who is a
a result. aerosol generating procedure (AGP). local point of contact, providing expertise and
Our trust has been very efficient and SLTs would arrive on a ward to conduct a a link between us and the infection control
thorough in issuing guidance on personal clinical swallowing assessment and request team, has also been invaluable.
protective equipment (PPE) and has respirator masks to protect us from AGP, to An emerging challenge with PPE is
produced action cards and online training the confusion of our multidisciplinary team the effects of wearing it for several hours
videos to support staff. The infection control (MDT) colleagues who are working long in a row as patients with COVID-19 are
team, which has been working flat out, shifts, including feeding patients cohorted; masks, visors and ‘base layer’
has still made time to respond to our many who were coughing, while wearing PPE do not necessarily need to be changed
queries. This has been hugely helpful but surgical masks. Collaboration with our between patients.
still challenges have been encountered, infection control team has removed this PPE takes its toll. Wearing it is
eg when there was a mismatch between mismatch leading to an update in trust exhausting—you overheat and your face →
May 2020 | www.rcslt.org Bulletin 13
12-14_Feature2 A_Bulletin May 2020_Bulletin 13 30/04/2020 13:55FEATURE
COVID-19
“Conducting assessments
behind a mask, when the
only facial expression is
what you can convey with
your eyes, is a challenge”
gets damp (at best) and at worst, very it is unrealistic to expect this to continue times. As a team, we have identified that the
sore. We have been thinking about how to without referrals being missed. We have current lockdown and the relentless focus
introduce more breaks and fresh air into therefore increased our presence at board on coronavirus across the media and social
our working pattern as a result, and accept rounds and hand-over meetings, while media—as well as our own immersion in it at
that it may be difficult to see the numbers of linking in more closely with AHP colleagues work—makes it very difficult to give ourselves
patients in a session we normally would. to ensure we find out about patients in a headspace. We see patients with the virus
timely fashion so that we can assist with safe with whom we resonate, and the relentless
All hands on deck and effective patient management and flow. flow of cases takes its toll. There is a quote by
None of the adult acute speech and language the author Dr Rachel Remen that sums this
therapy team has been redeployed due to Learning and adapting up: “The expectation that we can be immersed
the ongoing demands on our service from In terms of how we actually manage our in suffering and loss daily and not be touched
the COVID-19 response. However, our adult inpatients, we are learning and adapting here by it is as unrealistic as expecting to be able to
service has been a hive of activity as teams too. Conducting assessments behind a mask, walk through water without getting wet.”
prepare to deliver training that enables staff when the only facial expression is what you We are very lucky in our trust as there
to transition into different clinical areas as can convey with your eyes, is a challenge. We are many systems of support available,
and when the need arises (we are training are noticing increased delirium, which could including new wellbeing zones and access
our colleagues in the voice, cleft, and be for a number of reasons and needs careful to psychological support. In the immediate
paediatric acute teams to enable them to management, not helped by a lack of loved team, we have agreed to have a set ‘wellbeing
join us in the adult acute team, as needed). ones visiting and patients being greeted by a hour’ each week in which we can do whatever
We are excited about the cross-pollination of sea of unrecognisable ‘bots’ in PPE. we need to refresh mentally (without alcohol,
expertise that will no doubt arise from this Videofluoroscopy and fibreoptic endoscopic obviously!). We have frequent check-ins with
and have also trained up a large proportion evaluation of swallowing (FEES) are normally each other, as well as team huddles. We take
of acute SLTs to join our well-established integral to our routine management of regular breaks too and focus on ‘parking’ the
critical care team to meet the increased need dysphagia, with FEES playing a particularly day before going home via an end-of-day
there. Staff who were seconded to research crucial role in critical care. However, with debrief with a buddy, and going through a
fellowships have rejoined the clinical fold, the increased risks associated with the ‘going home checklist’.
so it is all hands on deck. procedures, they are not currently in our At a time when our social lives are restricted
For the first time in our trust’s history toolkit, so we’ve had to be even more focused by coronavirus, our work family has become
we are offering a seven-day and bank in our clinical assessments. We are also seeing an even more important source of support.
holiday service. This has been set up within patients in critical care who have had multiple These strategies are essential as we need
a fortnight’s notice and is from our existing intubations, with the likely associated to focus on our own mental and physical
resource on an overtime model. The success damage this causes, and are working hard health in order for us to last the distance of
of this is based on the dedication and team to create a risk assessment and protocol to COVID-19. There is no doubt that our response
spirit of the therapists themselves, and its enable us to safely restart our FEES service to this virus is going to be a marathon, not a
announcement was met with a round of when appropriate. The next stage in the sprint, but it has required a sprint start to get
applause from the wider critical care MDT. management of this virus will be the huge us on track. ■
The way we receive referrals has had to rehabilitation needs these patients will have—
change. We normally receive them centrally it feels like we’re seeing the tsunami on the
when the MDT make a request through our horizon, and the speech and language therapy Dr Sally Archer, consultant SLT and
electronic patient record system. However, team will need to be ready and adequately Claire Twinn, head of speech and language
the profile of staff covering all of the new resourced to meet this demand. therapy, Guy’s and St Thomas’ NHS
wards has changed dramatically, with new A final but vital observation has been the Foundation Trust, London
‘surge’ team members supporting existing importance of needing to look after ourselves Email: sally.archer@gstt.nhs.uk
staff, and MDT colleagues are so busy that through these strange and unprecedented @SallyArcherSLT
14 Bulletin May 2020 | www.rcslt.org
12-14_Feature2 A_Bulletin May 2020_Bulletin 14 30/04/2020 13:56Entire Video Library Online
• 56+ titles
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May 2020 | www.rcslt.org Bulletin 15
BUL.05.20.012.indd 15 30/04/2020 13:53FEATURE
SWALLOWING AWARENESS DAY
1
2
Swallowing
Awareness Day
2020
3
O
n 18 March the RCSLT
celebrated the fifth
1. SLT Angela Penny teamed up with local cafe
annual Swallowing
owner Christine to include dysphagia-friendly
Awareness Day; a foods on the menu, including crustless quiche,
day dedicated to smoothies and pureed soup. The RCSLT’s
raising awareness of dysphagia factsheets were also available for
dysphagia and how customers to read. “Our aim was to provide
3. After realising how many conversations
[local] residents with swallowing difficulties a
SLTs support people with eating, drinking revolve around food, SLT students Laura
friendly welcome at a cafe where they can enjoy
and swallowing difficulties. Sunnucks, Bethan Hill and Cat Choate from
the social side of eating out,” Angela said.
SLTs, students and other healthcare University College London took up the IDDSI
@AngelaPenny11
level 4 eating and drinking challenge. For a week
professionals across the UK took to social they swapped solid foods for thickened tea,
media to celebrate the day with passion and 2. Danielle Mulligan and colleagues armed with
porridge, soups, purees, smoothies and even
promotional swallow awareness materials, a
creativity. We saw an inspiring range of biscuit challenge, a presentation on wheels and
beer, taking to Twitter to share images of their
activities and events—catering staff taking #thickenerchallange.
thickened water, head to the wards of the Royal
@UCLGivingVoice
to wards to treat patients to modified tea Manchester Children's Hospital. @DMullNutri
parties; SLTs in schools talking to children
at snack time about dysphagia; training
sessions for modifying food; students SLTea Party Challenge
taking part in thickener challenges; and
even a bespoke, dysphagia-friendly This year we launched the ‘SLTea Party Challenge’
restaurant menu. to find the best recipe for a texture-modified
While some of your Swallowing afternoon tea. We’re pleased to announce
that the winner was the Marjon Giving Voice
Awareness Day events could not go ahead
Society. Their tasty-looking contribution came
due to COVID-19, we were glad to see
complete with sandwiches, cheesecake and trifle.
so many people around the world were Congratulations to them and a big thank you to
engaging with the campaign on social our judges: associate professor and IDDSI board
media, including those in New Zealand, member Dr Ben Hanson; RCSLT director of
Ghana, Japan and 20 other countries. professional development Judith Broll; and Oak
Some of our favourite Swallowing House Kitchen’s Preston Walker.
Awareness Day activities are featured here— You can find the winning recipe here:
search #swallowaware2020 on Twitter to bit.ly/3dLM5Zt
see them all. ■
16 Bulletin May 2020 | www.rcslt.org
16_Feature3 SAD_Bulletin May 2020_Bulletin 16 30/04/2020 13:56ADVERTORIAL
Starch-based found that repeated oral intake of up to
214 mg per kg of body weight per day
(approximately 12.8g xanthan gum per
thickeners vs gum- day for a 60kg individual) for 10 days was
well tolerated among most adults. While
some individuals experienced ‘undesirable
based thickeners abdominal discomfort’, this was not
considered to be an adverse effect. The
EFSA concluded that there are no safety
concerns for the use of xanthan gum as a
food additive at concentrations reported by
Downsides of gum-based
T
hickening agents are often the food industry (6).
used in the treatment of thickeners The table below provides an estimation of
dysphagia to improve bolus It’s important to recognise that gum-based how much thickening agent a patient would
control and prevent swallow thickeners are widely used in clinical practice consume at different IDDSI levels. It is not
aspiration. They bind with water to and are tolerated by the majority of patients. possible to accurately estimate how much
increase bolus viscosity, slowing the However, there may be some clinical xanthan gum a patient would consume from
entrance of thickened fluids into the contraindications in a minority of patients. the thickening agent, as manufacturers do
pharynx, which may reduce the risk This article focuses on evidence relating not provide this information. However, it’s
of aspiration (1). to xanthan gum, as it is one of the main likely that patients on higher IDDSI levels
Commercially produced starch- and ingredients in most gum-based thickeners. could be consuming more than the amounts
gum-based thickening agents have an of xanthan gum used in the trials above.
important role in clinical practice. Digestive problems Given its laxative effects at high doses, this
Gum-based thickeners represent a Animal studies have found that large doses could be problematic for patients with loose
newer generation of thickening agents of xanthan gum can induce soft stools stools due to a pre-existing condition such
and are increasingly popular among with increased frequency (3,4). However, as irritable bowel syndrome (that affects
healthcare professionals (HCPs) due to findings from animal studies cannot be around 10-20% of the general population
their clarity, stability, and resistance applied directly to humans. Additionally, (7)) or lactose intolerance.
to amylase. these studies used extremely high doses of The dosage of xanthan gum should also
However, there are certain clinical xanthan gum, which humans are unlikely to be carefully considered in those taking
contraindications for gum-based consume from an oral diet alone. medications and supplements which are
thickeners, supported by clinical One small human trial found that known to have a laxative effect. These may
research. Additionally, there is a moderate doses of xanthan gum (15g/ include (but are not limited to) magnesium
percentage of patients who will benefit day) caused similar digestive symptoms in (8), laxatives, metformin (9), certain
from and/or prefer starch-based humans over 10 days in 18 healthy men (5). antibiotics (10), chemotherapy drugs (11),
thickeners. Finally, it’s important to give The researchers concluded that xanthan cholesterol-lowering agents (12), and
patients autonomy when it comes to gum has a “highly efficient laxative effect” specific thyroid hormones (13). If there are
choosing their thickening agent. as it significantly increased stool output, contraindications for using xanthan gum, a
This article is written from a dietitian’s frequency of defecation, and flatulence, starch-based thickener may be more
perspective and has been sponsored by while having variable effects on gut transit appropriate.
AYMES International. It aims to time. The same study found that healthy NICE Clinical Guideline CG32 (Nutrition
encourage HCPs to think about their volunteers were asymptomatic if they Support for Adults) states that: “People
own clinical practice when working with consumed less than 15g of xanthan gum per with dysphagia should have a drug review to
patients who use commercially produced day, suggesting that at small doses, xanthan ascertain if the current drug formulation,
thickening agents for dysphagia. gum is unlikely to cause adverse effects. route and timing of administration remains
The European Food Safety Authority appropriate and is without contraindications
Similarities and differences (EFSA) re-evaluated the safety of xanthan for the feeding regimen or swallowing
Studies comparing the effectiveness of gum as a food additive in 2017. They process” (14). →
both groups of thickeners on swallowing
function and therapeutic outcomes Property Starch-based Gum-based
are limited. It is important to reiterate
that both starch-based and gum-based Viscosity High viscosity across a range High viscosity across a range
thickeners are clinically effective. A of temperatures of temperatures
comparative study of starch-based and
gum-based thickeners in the treatment Stability May continue to thicken Stable viscosity over time
of post-stroke oropharyngeal dysphagia over time
(OD) concluded that “both starch-based Clarity Cloudy appearance Translucent
and gum-based thickeners strongly
and similarly improve the safety of
swallow in chronic post-stroke OD by a Consistency Susceptible to amylase Amylase-resistant
digestion
compensatory mechanism" (2).
May 2020 | www.rcslt.org Bulletin 17
17-19_AYMES ADVE_Bulletin May 2020_Bulletin 17 30/04/2020 13:57ADVERTORIAL
References
1. Cichero JAY. Thickening agents used for
dysphagia management: Effect on bioavailability of
water, medication and feelings of satiety.
Nutr J. 2013.
2. Vilardell N, Rofes L, Arreola V, Speyer R, Clavé P. A
Comparative Study Between Modified Starch and
Xanthan Gum Thickeners in Post-Stroke
Oropharyngeal Dysphagia. Dysphagia. 2016.
3. Woodard G, Woodard MW, McNeely WH, Kovacs
P, Cronin MTI. Xanthan gum: Safety evaluation by
two-year feeding studies in rats and dogs and a
three-generation reproduction study in rats. Toxicol
Appl Pharmacol. 1973.
4. Edwards CA, Eastwood MA. Caecal and faecal
short-chain fatty acids and stool output in rats fed
on diets containing non-starch polysaccharides.
Br J Nutr. 1995.
5. Daly J, Tomlin J, Read NW. The effect of feeding
xanthan gum on colonic function in man: correlation
with in vitro determinants of bacterial breakdown.
Br J Nutr. 1993.
6. Mortensen A, Aguilar F, Crebelli R, Di Domenico A,
Frutos MJ, Galtier P, et al. Re-evaluation of xanthan
gum (E 415) as a food additive. EFSA J. 2017.
Amount of thickening agent consumed in 2 litres of fluids at different IDDSI levels* 7. National Institute for Health and Care Excellence
(published date: 2008 last updated: 2017). Irritable
Level 1 Level 2 Level 3 Level 4 bowel syndrome in adults: diagnosis and
management. Clinical guideline [CG61]. Retrieved
from https://www.nice.org.uk/guidance/cg61/
Number of scoops 1 2 4 6
chapter/introduction
added (scoop size: 1.2g)
8. Izzo AA, Gaginella TS, Capasso F. The osmotic
and intrinsic mechanisms of the pharmacological
Amount of thickening 12g 24g 48g 72g laxative action of oral high doses of magnesium
agent consumed in sulphate. Importance of the release of digestive
2 litres of fluid polypeptides and nitric oxide. Magnes Res. 1996.
9. Foss MT, Clement KD. Metformin as a cause of
*Calculated using a market-leading gum-based thickening agent (Resource ThickenUp Clear) late-onset chronic diarrhea. Pharmacotherapy. 2001.
10. Barbut F. Managing antibiotic associated
diarrhea. BMJ. 2002.
11. Stein A, Voigt W, Jordan K. Review:
Patient choice popular amongst HCPs and patients, there
Chemotherapy-induced diarrhea: Pathophysiology,
The Francis Report highlighted the may be some clinical contraindications in frequency and guideline-based management.
importance of giving people food and a minority of patients. Research suggests Therapeutic Advances in Medical Oncology. 2010.
fluid in a form they can safely consume, that xanthan gum may have a laxative effect 12. Fernandes R, Shaikh I, Wegstapel H. Possible
association between statin use and bowel
and of delivering care based on the needs when consumed in large amounts (>15g/
dysmotility. BMJ Case Rep. 2012.
and choices of patients (16). It forms part day), which could be problematic in patients
13. Brechmann T, Sperlbaum A, Schmiegel W.
of NICE Clinical Guideline CG32 (14). with pre-existing digestive conditions or Levothyroxine therapy and impaired clearance are
Anecdotal reports from HCPs suggest those who take certain medications or the strongest contributors to small intestinal
that some patients, particularly those supplements. bacterial overgrowth: Results of a retrospective
cohort study. World J Gastroenterol. 2017.
with a learning disability, prefer starch- It is important for speech and language
14. National Institute for Health and Care Excellence
based thickeners in the long-term. therapists and dietitians to work together (published: 2006 update: 2017). Nutrition support
Additionally, patients who are used to as part of a wider multidisciplinary team for adults: oral nutrition support, enteral tube
taking traditional starch-based thickeners to establish which type of thickener would feeding and parenteral nutrition. Clinical guideline
[CG32]. Available at: https://www.nice.org.uk/
may find it difficult to cope with switching be most appropriate for the patient. guidance/cg32/chapter/1-Guidance#oral-nutrition-
to newer gum-based products after Regularly reviewing patients is important support-in-hospital-and-the-community
long-term usage. It all comes back to to monitor for any adverse effects relating
patient choice—giving patients autonomy to their thickening agent. In some instances
and empowering them to make their own switching to a starch-based thickener may
decisions (where appropriate) about their be most appropriate. Finally, this article has AYMES International brings a fresh
choice of thickening agent. reiterated the importance of giving patients and innovative approach to delivering
autonomy when it comes to choosing a delicious and cost-effective oral
Conclusion thickening agent that meets their individual nutritional supplements and clinical
In conclusion, both gum-based and requirements. nutritional products.
starch-based thickeners have important
roles in clinical practice. While gum-based Harriet Smith, registered dietitian
thickeners are becoming increasingly and health writer www.aymes.com
18 Bulletin May 2020 | www.rcslt.org
17-19_AYMES ADVE_Bulletin May 2020_Bulletin 18 30/04/2020 13:58ADV0320-005
Dysphagia Series
Although clear gum-based thickeners have risen in popularity, research suggests that xanthan gum, one
of the ingredients in gum-based thickeners, may have a laxative effect when consumed in large amounts
(>15g/day1) : this may be one of the reasons some patients can’t tolerate gum-based thickeners or
simply prefer to stay on a starch-based thickener.
Thicken Aid is the most cost-effective starch-based IDDSI Level 1 Level 2 Level 3 Level 4
thickener on the market, and is much more
economical than Thick & Easy. Thicken Aid 11p 15p 19p 23p
Thick & Easy 20p 24p 28p 32p
Cost per 200ml drink 2
Order a free sample of Thicken Aid
Contact customercare@aymes.com or phone + 44 (0) 845 6805 496
AYMES International Ltd | P O Box 853 | Haywards Heath | RH16 9PL
1. Mortensen A, Aguilar F, Crebelli R, Di Domenico A, Frutos MJ, Galtier P, et al. Re-evaluation of xanthan gum (E 415) as a food additive. EFSA J. 2017
2. Based on MIMs, April 2020
BUL.05.20.019.indd 2 23/04/2020 11:23Katie Kathryn
K
Chadd Moyse
In our inaugural Research and Outcomes
1. Outcome measurement and
Forum, Katie Chadd and Kathryn Moyse clinical expertise
discuss how outcome measurement forms Outcome measurement provides
an essential component of evidence-based data that assists us with
practice reflecting on our own practice,
evaluating interventions we
provide and learning from
others. It therefore plays a role
in building clinical knowledge
and expertise, and our
understanding of what makes a
quality service.
2. Outcome measurement and
service-users’ preferences,
priorities and values
Outcome measurement is core
to providing person-centred
care. Working in partnership
Outcome measures with service users to identify
meaningful outcomes and
and EBP measures can help us to focus on
the priorities and preferences of
the people that we support. By
monitoring and documenting
E
vidence-based practice measurement have been meaningful change over time,
(EBP) as a subject is problematic, but one way of we are better placed to truly
regularly discussed conceptualising it is: “results or understand whether we are
within this section of visible effects of interventions… indeed meeting our service
Bulletin. But, as the RCSLT’s part of the quality cycle… users’ preferences.
organisational approach shifts the impact of interventions” may not be included for such
towards the greater inclusion of (Enderby, John and Petheram, 3. Outcome measurement and studies due to particular
outcomes and informatics into 2006). the external scientific evidence personal, demographic or
the research team, it is timely for To remind readers, when we Outcome measurement data multi-morbid clinical attributes.
us to start exploring EBP through talk about EBP, we are referring can complement the external As a result of this and many
the lens of one form of applied to an approach to practice scientific evidence, the third other contributing factors, it
data collection: outcome that uses information that is element in the EBP model. may or may not be feasible to
measurement. From now on, in triangulated from different Routinely collected implement interventions exactly
the ‘Research and Development’ sources to guide clinical outcomes data can assist as described in a study and
pages of the magazine (as they decision-making. with contextualising findings achieve the same outcomes. It
were called—you will see we The model of EBP alludes from research studies for the is therefore essential that we
have renamed them to reflect to three core aspects of local population. Just because collect data to monitor and
their new focus), we will be information: something appears to have been evaluate whether interventions
thinking about how collecting ■ Clinical expertise effective in a research study have an impact when we apply
routine clinical outcomes data ■ Service users’ preferences, does not mean it will also be them in our local context.
can develop your EBP, contribute priorities and values effective for the person you Furthermore, collecting
to improving quality of care, ■ External scientific evidence are working with. Hence it is data routinely on all of the
enrich the evidence base for our Where does collecting imperative that we carefully individuals we work with
interventions and empower you outcomes data sit in the model? monitor the outcomes of the can generate larger volumes
to have a role in all of these. The answer is, essentially, that work we carry out. Also, of information about these
outcomes data adds value to all the peer-reviewed evidence client groups than is currently
Adding value information sources required available to us typically consists available in the speech and
In the UK and internationally, to be an evidence-based of studies that have carefully language therapy literature. In
there is currently no standard practitioner. We can show this selected participants, who may the absence of representation
definition of outcome to be true by taking each part or may not be representative of of some of our most complex
measurement in the context of the EBP model in turn and the individuals we encounter on client groups in the peer-
of healthcare (HfMA, 2016). identifying how outcomes data our caseloads. The individuals reviewed literature, outcome
Attempts to define outcome feeds into each. we work with on a daily basis measurement can help to fill a
20 Bulletin May 2020 | www.rcslt.org
20-21_R and O Forum_Bulletin May 2020_Bulletin 20 30/04/2020 13:58You can also read
