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By Elyse Matson, MA CCC-SLP, SLP Resource
One of our initiatives for 2021 is to increase our SLP programming, thus providing a more cohesive and multi-disciplinary approach to care. Hiring SLPs can be challenging depending on the market. One way to increase the number of candidates for SLP positions is to consider hiring a newly graduated SLP, also referred to as a CFY.

What is a CFY? CFY stands for Clinical Fellowship Year. Think of it like a residency. It is a mentored experience to better transition SLPs from student to licensed and certified clinician. In order to hire a CFY, a licensed and certified SLP needs to agree to mentor for approximately nine months if it is a full-time position. This involves some supervision and guidance of the CFY, depending on the state regulations. In addition, the licensed SLP needs some training in supervision. These regulations vary by state.

There are numerous benefits to hiring a CFY. The new grad is likely to be motivated to learn, eager to build a caseload and willing to accept guidance. A CFY is not a student. If you hire a new grad SLP, they are a regular employee. The only difference is they require some supervision from another SLP. During the COVID-19 pandemic, ASHA is allowing tele-supervision. The mentor needs to be licensed in the state where the CFY will be working. See the changes for 2020 here: 2020 requirements ASHA SLP Crosswalk.

If the new grad will be the only SLP in the facility, make sure to talk with them about how they will handle that challenge so they are clear on what their role in the facility will look like. To help with recruiting efforts, consider stating in the position “CFY accepted,” which will help let new grads know they can apply. Whether they will join a team of SLPs or be the sole provider, hiring a CFY might be just what’s needed to invigorate your SLP programs.

Please feel free to reach out to me if you need assistance with interviewing and decision making with CFYs. Click here for more information from ASHA : https://www.asha.org/certification/completing-the-clinical-fellowship-experience/

Morgan Nebo, Dietary Supervisor at Victoria Post-Acute, and Aggie Smith, Flagstone Dietitian, provided a great presentation to the Flagstone DORs and SLPs on best practices for therapy and dietary collaboration with emphasis on ThinkThin!

Key takeaways from this presentation:
1. CMS — Quality of Care Intent: “To the extent possible, MAINTAIN or IMPROVE before complications arise.”

● Resident HYDRATION is the key (and the challenge) with thickened liquids.
● F692, Quality of Care Nutrition and Hydration, requires that a resident is offered sufficient fluid intake to maintain proper hydration and health.
● As a general rule, most residents will require 1500–2000 cc daily under “normal” circumstances — SLP collaboration.

2. Nutritional Assessment and Risk Identification: Collaboration with SLP and Food/Nutrition to assess a variety of areas.
3. Become familiar with using the information in PCC: i.e., Nutritional Assessment UDA along with CNA input/output reporting.
4. Collaboration is super important during quarterly assessments
5. Become familiar with the facility menu system in the affiliate you are servicing. Review the diet manual standards and follow facility nomenclature. If a facility-wide change is needed, collaborate!

The training was so successful, the LMS team is working on a recording so everyone in the organization can benefit from the great information and have continued collaboration for Think Thin!

By Dawn Thompson, DOR, Victoria Post Acute Care, El Cajon, CA

Over the last several months, Victoria Post Acute Care [VPAC] has honed in on vital sign monitoring as part of our daily practice in both nursing and therapy. I’ve been nominated to lead our vital signs committee, and during the next few weeks I’d like to share some of the best practices and education that assisted us through COVID and landed VPAC Vital Sign Grand Champions.

We’ll start with the vital sign we’re all monitoring daily, body temperature. After 8 months of daily screening, you’ve probably noticed a pattern and can guess your morning temperature within a few tenths of a degree; you’ve established your baseline temperature.

Do you know your residents’ baseline temperature? Would you be able to identify a fever and assist in early recognition of an infection?

Regularly measured body temperature is used to establish a baseline temperature and define the threshold temperature for fever. The elderly are noted with a lower baseline body temperature and a shift of 2.4*F above baseline is a fever, even when falling below definition of a fever at 100.4*F.

At VPAC, once a baseline temperature has been established, it is then added in special instructions in the Care Profile in PCC [See photo below]. This baseline temperature can then be used to assist in identifying any potential infection or COC with our residents.

Please don’t hesitate to reach out with any questions. (DawnThompson@ensignservices.net).

By Tamala Sammons, M.A., CCC-SLP, Therapy Resource
We have been focused on why it is so important to measure vital signs as part of our clinical practice. Not only does the data help us with early detection of sepsis, identifying patient instability, having comparative baselines during exercise, and knowing when to stop an activity, but it also helps us make better clinical decisions around patient care. Now, therapy teams need to also focus on capturing measured vital signs into our daily documentation practices.

Measuring and documenting vital signs starts at the evaluation to ensure treatment plans are designed to address challenges with varying diagnoses and to ensure we provide interventions accordingly.

Next, vital signs are measured during treatment sessions to support decisions around interventions being provided. The key for us as therapists is to capture the data from vital signs as a guide to what interventions we will provide, or stop providing. In other words, we need to do more than simply take and record vitals. We need to use vital sign data as tools to make clinical decisions.

For example:

● Mr. Smith has O2 weaning as a goal. OT is documenting patient is SOB during activity; however, no vitals were recorded at evaluation or in TENs. Data was only entered into PCC. Here is why capturing vitals in our clinical documentation is also needed: Documentation is further enhanced when the OT documents how many liters the patient is on and levels of O2 before the activity, five minutes into the activity, and after the activity. This documentation is specific to the therapy session and needs to be recorded in the TENs as it supports what physical activity the patient can tolerate as part of decisions around O2 weaning and overall improvement with ADLs.

● Mr. Jones has precautions with BP risk identified on the PT evaluation. However, upon review of daily TENs, BP is not captured in the documentation pre-, five minutes into, and post-exercise. BP was entered into PCC, which is great for simply recording data. However, using the data in a meaningful way in our TENs supports the clinical judgment of a therapist (i.e., what decisions during treatment were made based on BP readings?) and further supports medical necessity for care.

● Mr. Romero had a CHF exacerbation and the hospital record noted he has 45% ejection fraction and he has SOB with walking greater than 75 feet. Documented vitals are paramount to ensure that his treatment with functional activities or prescribed exercise are keeping his HR between 25-35% of his target HR.

Other Examples:

● Pt. “V” has SOB and needs to rest frequently. What do the vital signs tell us and do we change direction in treatment due to those measures?

● Pt. “I” is on 2L O2. PT is working on ther ex and gait. Does O2 change with exercise? How long does it take to get them to recover?

● Pt. “T” is medically complex and post-septic. What do we know about pts who have been septic? How are we ensuring we are monitoring for s/s of sepsis while in therapy? What vitals are recorded in our documentation to support our clinical treatment decisions?

● Pt. “A” is doing breathing exercises with SLP due to COPD. What is the patient’s respiratory rate pre-, during, and post-breathing exercises? What are the O2 levels? How do we know the interventions are working?

● Pt. “L” is a cardiac patient. How are vitals documented during treatment sessions to support exercise prescription? How do we know our plan is working?

Please continue to work with your teams to not only measure vitals, but more importantly, integrate the data into evaluation and treatment documentation to support skilled intervention decisions, capture clinical judgement, and demonstrate medical necessity of our services.

By Brian del Poso, OTR/L, CHC, RAC-CT, Therapy Resource
Next up in the series of interviews of our former DORs turned ED is the one and only Amy Gutierrez! She is not only a former DOR, but served as a Therapy Resource as well. Amy is currently the ED at Treasure Hills in Keystone. She was kind enough to share some of her thoughts with us:

As a DOR/Resource, you were in a good place in your career. What kinds of things were you thinking about when the thought of being an ED came up?
Jon (Anderson) was actually the one that brought it up in October of 2018 at the Leadership Summit meeting. Prior to that, I never really wanted the responsibility lol! I suppose that was when the seed was planted. Throughout that time period I considered taking my boards to becoming an Admin, I started asking questions to the other administrators. One of the most frequent questions I had was, “Is it fulfilling?” As a therapist and a resource, I know we make a difference and felt I had a purpose. I didn’t know if I would have the same sense of fulfilment as an ED. I was naïve to think that it wouldn’t be.

How did you come to the decision to push forward into the AIT/CIT program?
To be honest, I kind of jumped in. The position was offered to me at the beginning of October with the acquisition scheduled to happen in November. At that time, I was still in my Hybrid role as a DOR and Resource. I was fortunate enough to attend an AIT boot camp, which helped to solidify the decision I made in becoming an ED. As an Administrator, we are given an opportunity to change the lives of many. And where we do that as therapists and Resources, we have the opportunity to do it on a much broader stage. All of those little changes we want to make, or we wish the Admin would do, is now on us. I learned rather quickly nothing is ever as easy as it appears. We are entrusted with so much, at times it could feel overwhelming, but it’s in those moments you begin to see growth as a leader.

What do you think is the most important characteristic of a successful leader?
This is a hard question to answer. I admire so many of our own leaders but for different reasons. One of the most common traits they all have is their openness to give and receive feedback. They surround themselves with the right people. They share what they know and want every single person around them to be just as successful.

If you were to talk to a therapist about the ED role in general, what is the most important thing you would talk to them about?
Being open and honest about the things you don’t know. Ask questions, lots of them. I find myself calling my partners and resources multiple times a day. It’s OK not to have the answers. One of my mentors shared that with me early on. And it has saved me a million times over.

Any other thoughts for a therapist who might be thinking about becoming an ED?
You have to be ready for anything. I have been in my role for eight months now, and I can honestly say, I never expected to be an Administrator under the world’s current circumstances. But you do everything in your power for the people under your leadership and those entrusted to your care. Times and positions like these are what therapists are made for.

By Tamala Sammons, M.A., CCC-SLP, Therapy Resource

A new clinical campaign for our SLPs and IDT is the “Think Thin! A Path to Thin Liquids” approach. There is so much supporting evidence that promotes thin liquids over thickened liquids. When thick liquids are needed, then we need to consider utilizing the free water protocol.

Reasons to Think Thin:

Preventing Dehydration: Dehydration can lead to a variety of negative health consequences including:
• Changes in drug effects
• Infections
• Poor wound healing
• UTI’s
• Confusion
• Constipation
• Altered cardiac function
• Declining nutritional intake

Improving Quality of Life:
Traditional thought holds that aspiration of any material into the lungs can lead to aspiration pneumonia so many patients who have difficulty swallowing are placed on diet restrictions that avoid thin liquids.
However, a confounding evidence in the literature suggests that pulmonary aspiration of differing materials may not present an equal risk for the development of aspiration pneumonia. Aspiration will result in pneumonia only if the aspirated material is pathogenic to the lungs and the host resistance to the aspirated material is compromised. Research also discovered: “The risk of developing aspiration pneumonia was significantly greater if thick liquid or more solid consistencies were aspirated.” (Holas, DePippo, & Redding, 1994)

Being able to have Thin Water: Free Water Protocol
If a patient must be on a thickened liquid for any duration of time, research using a free water protocol found that fewer residents had UTI’s and dehydration and that when paired with proper positioning and oral care, there were no incidents of aspiration. Additionally, providing patients with thin water:
• Improves quality of life
• Improves Resident satisfaction with meals and less reports of thirst (Over 35% of patients are noncompliant with thickened liquids)
• Decreases risk of dehydration, UTI’s and pneumonia

Additional training information and materials will be coming over the next few weeks as we work to Think Thin!

Submitted by Tamala Sammons, M.A., CCC-SLP, Therapy Resource

The Mission:
Improve Sepsis identification early to improve patient outcomes.

The Why:
Sepsis was 20% of our Medicare Readmissions as an Organization in Calendar Year 2019.
With every hour that treatment is delayed for sepsis, the mortality rate increases by 8%. Understanding and educating our facilities on SIRS and a focused vital-sign campaign with an SBAR-specific focus will improve our care delivery and reduce readmissions, improve our patient satisfaction, and help with our change in condition process.

COVID-19 and Sepsis: A Physician’s Lens
While there is still a lot to uncover about the pathology and presentation of COVID-19, we have learned a great deal about this virus and its potential impact in our post-acute care facilities. During our experience at one of the early COVID-19 outbreak facilities, it was discovered that an early presentation of many COVID-19 patients was the presence of a fever. Unfortunately, these fevers were managed with the typical order for acetaminophen and cooling measures, effectively masking the fever and avoiding any further escalation of care until the patient reached a point of medical instability.Sepsis POSTette

As with any patient in a post-acute care facility presenting with fever, even before COVID-19, timing is absolutely critical. Other changes of condition such as chest pain or possible stroke have led to long-standing, conditioned responses to immediately send patients out via 911. Fever is often the hallmark sign signaling the beginning of a patient experiencing sepsis — a diagnosis that carries a much higher chance of mortality, especially in the post-acute care population, but up until now has not received the attention it deserves. Oftentimes a febrile episode is masked or ignored, leading to a cascade of events leading to further demise, accelerated by a virus that now has the potential to spread like wildfire.

We are now at a point where identification of fevers (and other changes of condition) should signal a “code” event, essentially alerting the clinical team to provide immediate identification, isolation, and intervention. With every hour that a fever is ignored, the mortality rate for a potential sepsis patient increases by 8%. This simple, yet widely underappreciated clinical practice can prove to be a pivotal step in reducing the mortality in not just our COVID-19 patients, but in any patient who is on the path of developing sepsis. — Dr. Pouya Afshar

For more information, click here for our Sepsis POSTette

Submitted by Tamala Sammons, M.A., CCC-SLP, Therapy Resource, Flagstone, Pennant, Sunstone, Milestone, Endura, Monument

Vital signs are the objective measurements of temperature, pulse, respirations, and blood pressure as a clinical means to assess general health. Additionally, many include Pain and Gait Speed as the fifth and sixth vital signs.

Vital signs are critical indicators of patient status, both at rest and during exercise/activity.

Therapists treat patients with many complicating conditions, such as:

• Respiratory conditions — pneumonia, COPD/chronic bronchitis, emphysema, asthma, atelectasis, etc.
• Cardiovascular conditions — CHF, hypertension, etc.
• Metabolic conditions — renal failure, diabetes, etc.
• Infection conditions — sepsis; Systemic Inflammatory Response Syndrome (SIRS), etc.

Taking consistent vital sign measurements will help ensure therapists have good data related to respiratory function, cardiovascular function, endurance, and a patient’s ability to tolerate functional activity.

As clinicians, it’s not only important to take vital signs, but also measure them against exercise/activity. In other words, vitals should be taken:

• Before the exercise (to establish a baseline);
• 6 to 8 minutes in the exercise; and
• 5 minutes after the exercise (recovery).

This information will allow clinicians to determine if target heart rates are being attained, any changes in condition, and/or if treatment adjustments need to be made, etc.

Consistent vital sign measurements also help detect medical condition changes. For example:

Sepsis early warning signs (these changes need to be reported immediately):

• Temperature higher than 100.4° F or lower than 96.8° F
• Heart rate greater than 90 beats per minute
• Respirations greater than 20 breaths per minute

Respiratory rehab considerations:

• A resting HR > 100 bpm is a relative indicator of patient instability.
• If lower than 90%, there is an inadequate oxygen supply, and less than 70% is life-threatening.
• Normal resting respiratory rate is 12-20 breaths per minute. “Normal” respiratory rate for an individual with pulmonary disease may fall outside these parameters. It is important to establish what is “normal” for each patient. Respiratory rate needs to be monitored before, during and after exercise.

Using vital signs to determine exercise termination:

• Significant blood pressure changes
  • o BP>200/110
  • Lightheadedness; BP drops >20 mmHg
  • No more than an increase of 20mm Hg with activity
  • Oxygen saturation <90%
• Severe shortness of breath
• Noticeable change in heart rhythm

It’s important to know the normal ranges for each vital sign along with considerations for an aging population. Additionally, it’s also important to know what medications patients are taking and if those medications may interfere with vital sign measurements.

For example:

• The medicine digoxin used for heart failure and blood pressure medicines called beta-blockers may cause the pulse to slow.
• Diuretics (water pills) can cause low blood pressure, most often when changing body position too quickly.

Take time to ensure every member of the Therapy team is taking vital signs consistently and throughout treatment sessions as recommended. Consider hosting a training lab if any skills need to be refreshed. Ensure team members have access to vital sign equipment (consider vital sign kits for each team member).

For more information on the details of vital signs, please refer to the Vital Signs POSTette, Pain Management POSTette, and Clincally Complex POSTette.

For training tools, check out these resources:

• Training video on taking blood pressure: https://www.youtube.com/watch?v=UGOoeqSo_ws
• Training video on all vital signs: https://www.youtube.com/watch?v=JpGuSxDQ8js
• LMS video available on Vital Signs: How to Measure Vital Signs REL-PAC-0-HMVS 1 hour