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S
peech
P
athology
A
ustralia
Work– l i f e balance : preserv i ng your soul
Data audit
Data pertaining to the weekend caseload has been collected
since November 2001. This data includes occasions of service
(OOS) provided, OOS required but not provided, new
referrals, weekend diet upgrades, weekend diet downgrades,
number of patients who commenced oral diet or enteral
feeding on the weekend, and number of diet changes
recommended on Fridays.
Data was analysed retrospectively for the initial 10 weeks
of the weekend speech pathology service in 2002 and in three
subsequent 6-month periods from April 2003 to September
2003, October 2003 to March 2004 and September 2005 to
February 2006. The initial 10-week data collected was extra
polated to provide a 6-month sample consistent with the
other time periods recorded.
hours during the week in the department to prevent isolation
and allow inclusion in department activities and training (for
a total of 0.2 FTE). New graduate clinicians have generally
been recruited to the position. The senior speech pathologists
within the department provide telephone supervision to the
weekend speech pathologist on a rostered basis. The weekend
speech pathologist is required to contact the supervising
speech pathologist via mobile phone to discuss issues
pertaining to prioritisation, critical decision-making and
service delivery. The supervising speech pathologist is paid
an on-call allowance.
Scope of service provision
The weekend service is provided to inpatients with swallow
ing, speech and/or language difficulties. Weekend speech
pathology services are not provided to patients with trache
ostomies or laryngectomies due to difficulties recruiting
speech pathologists with competencies in these specialised
areas and the time requirements. Patients referred to the
weekend service are prioritised according to the schedule set
out in table 1. Examples of high priority include new admis
sions with acute dysphagia or patients who have deteriorated
over night. Examples of lower priority include new admissions
with acute onset of communication disorders or patients who
have improved over night and require review for potential to
upgrade their diet. The supervising senior speech pathologist
participates in patient prioritisation with the weekend speech
pathologist (table 1).
Table 1. Current prioritisation criteria
Priority
Description
1 New admissions to the hospital with acute dysphagia
2 Patients who have deteriorated over night
3 Patients who are nil by mouth without stable enteral
feeding
4 Patients at nutritional or dehydration risk due to dys
phagia
5 Patients commenced on an oral diet that requires
review to ensure safety
6 Patients with fluid consistency upgraded on Friday
who require review to ensure safety
7 Patients with food consistency upgraded on Friday
who require review to ensure safety
8 Patients requiring a direct swallowing therapy program
9 Patients requiring education regarding dysphagia
management prior to discharge
10 New admissions to the hospital with acute onset of
communication disorders
11 Patients who improve overnight and could be reviewed
with respect to an upgrade
Table 2. Numbers of occasions of service (OOS) and new
referrals recorded for selected time periods between
November 2001 and February 2006
Nov 2001 – Apr 2003 –
Oct 2003 – Sept 2005 –
May 2002
a
Sept 2003 March 2004 Feb 2006
OOS
270
305
276
235
New
referrals
12
72
51
46
a
Data for November 2001 to May 2002 was extrapolated
from actual data from November 2001 to February 2002.
Inpatients on the current speech pathology caseload who
have not been referred to the weekend service by their
treating speech pathologist may be subsequently referred to
the weekend service by medical, nursing, allied health staff
or family and are prioritised according to the prioritisation
schedule. The weekend speech pathologist discusses these
re-referrals with the supervising clinician prior to seeing the
patient. The supervising speech pathologists conduct regular
audits of referrals to monitor consistency and appropriateness
of referrals across the department.
Results
Numbers of occasions of service and new referrals recorded
between November 2001 and February 2006 are reported in
table 2. In the period November 2001 to February 2002, 95%
of the OOS were for dysphagia with 5% for speech or lan
guage difficulties. Four of the six new referrals to the
weekend service commenced enteral feeding on the day of
review, thus minimising hydration or nutritional complica
tions as a consequence of their nil by mouth status. During
this period 16 patients had their diet consistencies upgraded.
A further 14 patients had their diet consistencies
downgraded, thereby reducing the risk of aspiration. There
was an average of 11 OOS per weekend during each data
collection period with no significant increase over time. The
number of new referrals increased from 12 in the initial data
collection period to 46 in the finale data collection period.
Discussion
The JHH weekend speech pathology service has successfully
provided management of dysphagia, speech and language
difficulties to an adult inpatient population within the acute
setting for almost six years. This weekend service reduces
the number of new referrals received on Mondays and
enables clinicians to implement dysphagia management
changes on Friday knowing that the patient can be monitored
over the weekend. Prior to initiating the weekend service,
potential diet upgrade decisions on Friday were often delayed
until the following Monday to enable monitoring. This delay
could prolong hospitalisation and affect progress in meeting
speech pathology, medical and discharge goals. Senior
supervision over the weekend is necessary to minimise
pressure of time management and increased caseload
demands. The ability to refer to the weekend service
anecdotally contributes to reduced weekday workload stress
among speech pathologists and increased patient satisfaction.
The service also manages patients who are suitable for