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SLP Service Delivery Considerations in Health Care During Coronavirus/COVID-19

Updated October 8, 2020

ASHA recognizes that many of our members who work in health care settings are in situations in which they are expected to provide care for patients with suspected Coronavirus/COVID-19, or those who are at a high-risk for contracting it. Speech-language pathologists (SLPs) continue to do an outstanding job meeting the emerging needs of patients and their communities, sometimes in less than ideal situations as part of interprofessional teams. ASHA continues to advocate for your safety and welfare related to clinical and professional issues with law makers, governing bodies, and employers, and will share updates as we receive them. The following information has been compiled to help in decision making related to patient care and personal safety for SLPs in health care, and will be updated as the recommendations related to COVID-19 evolve.

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Job Classification of Health Care-Based SLPs: Essential/Non-Essential

Positions are typically designated as essential on a contractual, seasonal or situational basis, e.g., in the event of a weather-related emergency or a public health crisis. It is typically included in the employee contract signed upon hire. Please refer to your own organization’s employee handbook for specific guidance.

The designation of essential or non-essential employee is usually assigned by one or more of the following entities:

  1. an employer;
  2. an employee union; 
  3. the federal government during national emergency: for example, specifically in response to COVID-19, the U.S. Department of Homeland Security has designated speech pathologists [sic] as “Essential Critical Infrastructure Workers” in an advisory to state/local governments [PDF] (page 5); 
  4. state governments in times of emergency. For example, during the COVID-19 pandemic, the governor of the state of New York [PDF] defined the classification as follows: “For the purpose of this directive, essential employees are defined as anyone whose job function is essential to the effective operation of their agency or authority, or who must be physically present to perform their job, or who is involved in the COVID-19 emergency response. Non-essential employees are defined as anyone who does not need to be physically present to perform job functions, or they are not required to meet the core function and programs of their agency during this emergency response.” Many employers providing health care in New York are choosing to interpret this to include SLPs. 

Ideally, managers need to communicate with their essential staff regarding expectations, work assignments, and relevant operational contingencies. 

The American Health Care Association (AHCA) and the National Center for Assisted Living (NCAL) released a joint statement [PDF] on the role of physical therapy, occupational therapy, and speech-language pathology to reduce the spread of COVID-19 that also provides additional guidance related to this issue. 

While ASHA cannot designate the employment classification of SLPs and audiologists as essential or non-essential employees, the Association is actively engaged in advocating on behalf of SLPs engaged in service delivery during COVID-19. ASHA is engaging with some employers and their oversight bodies, to clarify the value of speech-language pathology services and the need to protect the health and safety of SLPs. 

In-Person Speech-Language Pathology Services

The Centers for Disease Control (CDC) recommends that each facility and type of practice setting completes their own risk assessment to establish guidance regarding provision of SLP services. The CDC encourages health care facilities to explore options for optimizing telehealth services, when available and appropriate. ASHA encourages SLPs to discuss patient and provider risks of service delivery with their employers to determine best course of action for in-person services. Since many states’ emergency declarations classifying SLPs as “essential” workers (e.g.,  Massachusetts [PDF]) override the Association and employer-level guidance, ASHA is unable to provide broad national directives relating to this issue. For more information on in-person service delivery, see the CDC updated Guidance for Direct Service Providers

ASHA recognizes that many of our members who work in health care settings are in situations in which they are being expected to see patients with suspected coronavirus/COVID-19, or those who are at a high-risk for contracting it. Speech-language pathology services are a central part of a patient’s plan of care.  In many health care settings, the SLP facilitates the patient’s ability to return to their homes quickly or remain in their homes as safely as possible while minimizing the risk of infection. SLPs are competent in infection control procedures, contribute to the patients continued quality of life, and are an integral part of the care team for a patient’s safe recovery and discharge to home. 

While the welfare of the patient is paramount, ASHA’s Issues in Ethics: Client Abandonment states, “no clinician is ever ethically required to work...in physical danger in order to offer client care.” For staff who may be at higher health risk, your employer may consider alternatives to reduce the potential exposure to clients/patients/students who are ill. Depending on the current CDC Travel Health Notice information, you may want to ask clients/patients/students and families about their recent travel plans and consider a waiting period for in-person encounters in the interest of everyone’s safety.  

Limited Access to Personal Protective Equipment (PPE)

The following resources provide relevant information specifically related to access and use of PPE during the COVID-19 pandemic: 

If SLPs and their colleagues are unable to access appropriate PPE for service delivery during COVID-19, they are encouraged to voice their concerns to OSHA and local departments of health and human services (HHS), after appropriate engagement with their employers. 

Many SLPs are concerned about client abandonment if they refuse to provide services without appropriate PPE. ASHA’s Issues and Ethics Statement on Client Abandonment states that some disruptions of clinician-client relationships are involuntary. As such, “clinical relationships may also be interrupted if an organization decides to close a program or when natural disasters occur. It is expected that even in these types of situations, practitioners would hold paramount the welfare of the clients they serve; however, no clinician is ever ethically required to work without pay or to place themselves in physical danger in order to offer client care,” (ASHA, 2019). 

Prioritizing Patient Care

COVID-19 has had unprecedented impacts on service delivery, impacting healthcare workers and the patients they serve. ASHA maintains that decisions about patients’ care should be made based on the clinician's professional judgement and clinical expertise, in accordance with the ASHA Code of Ethics and  SLP Scope of Practice. Every patient presents with unique characteristics and medical situations. Therefore, if clinicians are faced with dilemmas of prioritizing patients, decisions should be made using a team approach. CMS’s  Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes (REVISED) [PDF] offer additional recommendations stating “...facilities should maintain a person-centered approach to care. This includes communicating effectively with residents, resident representatives and/or their family, and understanding their individual needs and goals of care. Facilities experiencing an increased number of respiratory illnesses (regardless of suspected etiology) among patients/residents or healthcare personnel should immediately contact their local or state health department for further guidance.” 

Documentation of Delays/Gaps in Services 

Due to this national emergency there may be unavoidable delays in care, or instances when one or more disciplines cannot provide care. In cases where a clinician is unable to see the patient, those specific reasons should be documented in the patient’s medical record and communicated to the healthcare team, while providing alternate solutions for the patient whenever possible. 

If there are interruptions to clinical services that delay continued access to care, here’s some additional guidance: 

  • Review patients’ plans of care and consider making any updates or modifications that may be necessary to account for patient access issues related to COVID-19 (e.g., contacting the family by phone for discharge planning, providing treatment only in the patient’s room, following CDC guidance for PPE while providing services, etc.) 
  • Communicate with patients and their families to help them understand the situation and assure them that you are doing all that you can to provide (or resume) services; and 
  • Ensure that all members of the care team are documenting in the medical record their efforts to adhere to the patient’s plan of care, including all refused attempts to see patients in-person and all alternative methods used to perform patient visits (e.g., virtual visits via telepractice or e-visits). 

Multisite Service Delivery

There is no clear answer to this issue since different health care settings and organizations are assessing their risk for disease transmission differently. Health care providers are being strongly encouraged to enact policies that limit disease transmission, especially between vulnerable populations. However, every facility needs to use the resource provided by the CDC to complete its risk assessment for and public health management of healthcare personnel with potential exposure in a healthcare setting to patients with coronavirus disease (COVID-19).  

The American Health Care Association (AHCA) and the National Center for Assisted Living (NCAL) released a joint statement [PDF] on the role of physical therapy, occupational therapy, and speech-language pathology to reduce the spread of COVID-19. Recommended changes include discontinuation of group and concurrent treatments, limiting delivery of therapy in resident rooms, and the use of social distancing. The joint statement also advises against therapists moving between buildings, if COVID-19 is discovered in one building. 

CMS has issued specific guidance for service delivery in skilled nursing facilities (SNFs) [PDF] which indicates that “Facilities should identify staff that work at multiple facilities (e.g., agency staff, regional or corporate staff, etc.) and actively screen and restrict them appropriately to ensure they do not place individuals in the facility at risk for COVID-19.”  

CMS has also issued guidelines for home health and hospice [PDF] services that address how to screen home health patients for COVID-19, when staff should avoid home visits, if and when patients with confirmed COVID-19 should be transferred to a hospital, and special consideration for patients requiring therapeutic interventions. 

ASHA recommends implementation of infection control guidelines from the Centers for Disease Control (CDC) and World Health Organization (WHO) who propose specific recommendations for health care workers. However, ASHA recognizes that many of our members who work in health care settings that are facing acute (global) shortages of PPE. ASHA prioritizes the health and safety of its members and has strongly encouraged health care organizations with whom it has engaged in advocacy, to ensure appropriate supply of PPE for SLPs for all aspects of service delivery. Per Occupational Safety and Health Administration (OSHA), “Employers of healthcare workers are responsible for following applicable OSHA requirements, including OSHA's Bloodborne Pathogens ( 29 CFR 1910.1030), Personal Protective Equipment ( 29 CFR 1910.132), and Respiratory Protection ( 29 CFR 1910.134) standards.” See the  Standards page on the OSHA website for additional information on OSHA requirements. 

Job Responsibilities Outside Scope of Practice

Many SLPs have indicated that, during COVID-19, their employers ask them to engage in tasks not directly related to their scope of practice (multiskilling). Multiskilling is often used in an attempt to enhance cost-effectiveness, efficiency, quality, and coordination of services. The SLP Scope of Practice is written in broad terms and specific activities, such as suctioning or taking blood pressures, are not mentioned. SLPs may complete these tasks and others as a function of their job responsibilities. ASHA's Code of Ethics states that clinicians must be competent by virtue of training, education and experience to perform any activities. Thus, appropriate training and support is necessary for an SLP to undertake any activity in which they are not already competent. It is advisable for your facility to develop a written policy that addresses the level of involvement and training that SLPs will have, and a mechanism for verifying their competency. ASHA has a position statement and technical report on multiskilling that offer additional guidance. During COVID-19, it is important to note that states may issue executive orders that can override the Association or employer policies. For example, the governor of Maryland issued an executive order on March 3, 2020, that overrides state licensure board limitations.

Please check your own state executive orders for the latest guidance on the issue. 

Return to Work After Exposure to COVID-19 

The CDC has established Criteria for Return to Work for Healthcare Personnel with Confirmed or Suspected COVID-19. Employers are expected to make appropriate risk assessments for their staff and patients before permitting re-entry of employees suspected to have exposure to coronavirus into their facilities. 

Aerosol Generating Procedures

Aerosol generating procedures (AGPs) result in the release of aerosols/droplets that can lead to the spread of respiratory infections. SLPs may engage in several procedures that can result in generation of aerosols, specifically by the trigger of the cough reflex. ASHA recommends that employers provide SLPs adequate protection from droplet transmission during AGPs consistent with the CDC recommended guidelines for personal protective equipment (PPE). ASHA has developed  additional guidance regarding aerosol generating procedures and appropriate PPE.

Modifications to Dysphagia Services During COVID-19

Since dysphagia assessment and treatment are classified as aerosol generating procedures, and many facilities are limiting access to instrumental assessments of swallowing, SLPs may have to provide dysphagia services in less-than-ideal conditions during the pandemic (e.g., creating a plan of care relying solely on clinical swallow examination with no input from an instrumental exam). While not optimal, ASHA recognizes that these constraints exist and that clinicians need to make reasonable accommodations to continue delivery of medically necessary, skilled services. For further information on this topic, ASHA's SIG 13 (Swallowing and Swallowing Disorders) has produced web recording with contribution from experts from the Dysphagia Research Society (DRS), the American Board of Swallowing and Swallowing Disorders (ABSSD) and the ASHA Health Care Economics Committee (HCEC). 

SLPs' Role in Endoscopic Procedures 

SLPs have a critical role in performing Fiberoptic Endoscopic Evaluation of Swallowing (FEES) to inform dysphagia management. Revised guidance [PDF] from the Centers for Medicare & Medicaid Services (CMS) does not recommend delaying endoscopic procedures, but instead encourages risk assessment based on a tiered framework to conserve critical resources such as ventilators and personal protective equipment (PPE), as well as limit exposure of patients and staff to the coronavirus. The Centers for Disease Control and Prevention (CDC) also offers a similar risk assessment protocol to determine if services need to be provided.

Since existing evidence indicates that viral density is greatest in the nose and nasopharynx, it is likely that use of instrumentation in and through these areas would lead to increased risk for transmission of COVID-19 in providers completing these tasks. Additionally, procedures such as FEES may involve the use of sprays, which can aerosolize the pathogens on the mucosa.

Current evidence is insufficient to fully determine the risk of aerosol generation during procedures such as FEES and flexible laryngoscopy with or without stroboscopy. It is unclear whether procedures themselves raise the risk for aerosol generation or if they increase the risk of patients’ reflexive coughs and sneezes that can result in aerosolization. ASHA recommends performing procedures that present a higher infection risk (e.g., aerosol-generating procedures) with additional caution. We also recommend that these procedures be performed only after pre-screening COVID-19 status and performed only with appropriate PPE recommended by the CDC.

ASHA encourages SLPs to work collaboratively with their medical facilities to draft policies that balance patient needs and clinician safety. ASHA also encourages clinicians to employ a day-by-day, data-driven assessment of the changing risk–benefit analysis to influence clinical care delivery. Clinicians are encouraged to avoid blanket policies and to instead rely on frequent review of data and emerging evidence, independent clinical judgment, and site-specific understanding of the medical and logistical issues in play. 

SLPs' Role in Videofluoroscopic Swallow Studies (VFSS) 

ASHA supports the guidance of  The American College of Radiology (ACR) which states “The ACR fully supports and recommends compliance with the Centers for Disease Control and Prevention (CDC) guidance that  advises medical facilities to “reschedule non-urgent outpatient visits”. This includes non-urgent imaging and fluoroscopy procedures, including but not limited to: screening mammography, lung cancer screening, non-urgent computed tomography (CT), ultrasound, plain film X-ray exams, magnetic resonance imaging (MRI) and other non-emergent or elective radiologic and radiologically guided exams and procedures.”  Clinicians should take a person-centered and team-based approach for clinical decisions about the necessity and urgency of videofluroscopic swallow studies (VFSS).  

Considerations When Providing Voice Services in the Absence of Endoscopic Evaluation During Coronavirus/COVID-19  

ASHA has prepared guidance to help SLPs make informed decisions about providing voice treatment in the absence of laryngeal visualization during COVID-19. Because of concerns about the spread of COVID-19 through aerosol generating procedures, some otolaryngologists and SLPs are deferring laryngeal visualization except when deemed vital and the benefits are judged to outweigh the risks. Here is additional guidance regarding voice service delivery during COVID-19.  

Telepractice in Health Care Settings

Telepractice is a viable service delivery models for all health care settings for clients of all ages, depending on the patient appropriateness. Some payers are expanding coverage for telepractice services in health care settings, especially during the pandemic. Both  assessment and treatment services may be provided via telepractice as appropriate. Learn more about use of telepractice for management of dysphagia and  neurogenic communication disorders from recorded discussions (not available for ASHA CEUs).

Related Online Events

  • Recorded conversation on "Dysphagia Management During COVID-19: Where Are We Today?" (sponsored by Special Interest Group [SIG] 13, Swallowing and Swallowing Disorders).
  • Live web discussion on Telepractice Considerations: Neurogenic Communication Disorders (sponsored by Special Interest Group [SIG] 2, Neurogenic Communication Disorders).
  • Live web discussion on Dysphagia and Telepractice During COVID-19 and Beyond.
  • Recorded conversation on management of individuals with COVID-19 in post-acute care (sponsored by Special Interest Group [SIG] 15, Gerontology). Watch the video.
  • Recorded conversation with a panel of experts answering member questions about dysphagia services during COVID-19 (sponsored by Special Interest Group [SIG] 13, Swallowing and Swallowing Disorders).
  • ASHA hosted a Virtual Town Hall focusing on speech-language pathology service delivery considerations in health care because of COVID-19. Watch the video.

Additional Resources

ASHA Corporate Partners