Clinical decision-making in acute care requires consideration of patient and contextual factors to facilitate optimum patient outcomes while ensuring equity within resource constraints. Speech Pathologists’ (SPs) clinical decisions aim to avoid negative consequences of dysphagia, including malnutrition, dehydration, increased hospital length of stay and poor quality of life. Recent evidence suggests only 10% of patients referred for dysphagia receive a VFSS in acute settings, despite it being considered a gold standard assessment tool. This qualitative study explored decision-making experiences of acute SPs who refer patients for VFSS. Research questions addressed how SPs make VFSS referral decisions, why some patients are not referred and perceived outcomes of VFSS referral decisions for acute adult inpatients. Participants were 18 SPs drawn from five acute hospitals across a large metropolitan health district. Four focus groups were conducted and analysed using Braun and Clark’s reflexive thematic analysis. Findings reflected participants’ experiences of VFSS decision-making as a complex process with significant impacts within acute care. Three themes were identified: VFSS decision-making is core to SP’s role and professional identity in acute care. VFSS can identify a ‘missing piece’ in dysphagia assessment, enhance SP’s profile, and build competence and confidence in dysphagia management. VFSS is a tool for patient-centred care. VFSS can facilitate quality and efficiency of care and empower patients and families as decision-making partners. Prioritisation is a necessary, driving force for VFSS decision-making. Prioritisation is challenging but essential for managing strong demand with limited resources. Patients are prioritised based on risk and urgency. VFSS is not appropriate for all acute patients with dysphagia. SPs highlighted the importance, complexity and challenges of decision-making regarding VFSS receipt in acute care. While VFSS can benefit suitable patients, SPs must prioritise to manage resource constraints, and not all suitable patients can access VFSS in acute care.

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