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AAC in the ICU: Critical Issues and Preliminary Research

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1 AAC in the ICU: Critical Issues and Preliminary Research
Mary Beth Happ, Ph.D., R.N. Kathryn Garrett, Ph.D., CCC-SLP Tricia Roesch, B.S.N., R.N. * * * * * * * * * * * * * * * School of Nursing University of Pittsburgh Duquesne University, Pittsburgh PA ASHA Convention November Chicago


3 Overview Part I: Literature Review
Part II: Feasibility study of electronic VOCAs in the Surgical Otolaryngology Unit and Case Example Part III: Feasibility study of electronic VOCAs in the Medical Intensive Care Unit Part IV: NIH-funded Intervention Study The SPEACS Project

4 Note: Please refer to the Microsoft Word document by the same title for a narrative version of this presentation The Word document will also contain the reference list.

5 Part I Background

6 Descriptive reports of the mechanical ventilation experience in the ICU
Patients experience: FEAR PANIC STRESS As a result of the inability to speak

7 Nurse-Patient communication in ICU:
Brief (< 5 min), task-oriented, commands & reassurances during physical care.

8 Patients typically communicate with nods, gestures, and mouthing words.

9 ICU interactions do NOT usually involve
communication of the patient’s ideas, patient’s initiation of messages or elaboration.

10 Communication difficulty with mechanically ventilated (MV) patients - related to illness severity, anger (Menzel, 1998) Greater difficulty communicating with family than with nurses Under-recognition & high levels of pain reported in MV patients (SUPPORT studies) RNs/MDs more likely to communicate with patients who are more responsive.

11 Statement of the Problem
Few data-based communication intervention studies with acutely/critically ill adults have been published (Dowden et al, 1986; Stovsky et al, 1988) Alphabet & picture boards preferred by a critical care survivors (n=5) (Fried-Oken et al, 1991)

12 Clinical case reports Introducing AAC preoperatively & word banking (Costello, 2000) Multidisciplinary post-operative AAC plans for head and neck cancer patients (Fox & Rau, 2001) Descriptions of AAC use in ICU (Fried-Oken, 2001)

13 A need exists for: Specific data on communication interventions for nonspeaking, intensive care unit patients Analysis of high tech versus low tech interventions Perceptual, qualitative, and quantitative analyses Comparisons between different ICU populations Usage data as well as interactional data

14 General Design of 2 Feasibility Studies

15 Purpose Explore the feasibility of electronic voice output communication aids (VOCAs) for use with nonvocal patients in a medical ICU and following head-neck cancer surgery.

16 Research Questions

17 What are the … Patient characteristics (illness severity, neuromotor ability) Usage patterns (message categories, frequency, assistance required) Communication quality (ease, satisfaction) Barriers to communication …when VOCAs are used by hospitalized adults?

18 Complementary Design QUAL + quan No hypotheses
Purposive-theoretical sampling Small samples Morgan, 1998

19 University of Pittsburgh Medical Center - Otolaryngology surgical unit
Settings: University of Pittsburgh Medical Center - Otolaryngology surgical unit - Medical ICU – 20 beds Entry Criteria: Respiratory intubation Responsive to verbal stimuli Follows commands consistently Initial Cognitive-Linguistic Screen* * Dowden, Honsinger & Beukelman, 1986

20 Procedures

21 Education & Set-Up Nurse Inservice (15 min)
Patient Instruction (20 min) + reinforcement Message Inventories What does he/she want to say? To whom? How? *Costello, 2000

22 Data Collection Enrollment Pre-test Ease of Communication Scale2
APACHE, Motor Screen1 Daily Observations (20min) Chart Review Extubation Post-test Ease of Communication Scale2 Exit Interviews 1. P. Dowden et al. (1986) L.. Menzel (1998).

23 Head and Neck Surgical Unit
Part II Pilot Research: Head and Neck Surgical Unit

24 Funding: AACN/ Sigma Theta Tau ONS Foundation/ OrthoBiotech
Mentorship/Consultation: Dr. Richard Hurtig, University of Iowa Stephanie Williams, SLP, Dynavox Systems, Inc Funding: AACN/ Sigma Theta Tau ONS Foundation/ OrthoBiotech Equipment donations: DynaVox Systems, Inc. WordsPlus, Inc. AbleNet

25 TM DynaMyte Electronic VOCAs Message Mate TM

26 Examples of Patient Message Screens DynaMyteTM

27 MessageMateTM 1 2 3 4 SICK COLD TV Say PAIN Back Space Clear BATH

28 Basic Messages Pain Shortness of Breath Suction Help! Hot/Cold
Home/Family Anxiety/Worry

29 pole swivel arm

30 Qualitative Data Analysis
Fieldnotes and interviews coded for: method content barriers facilitators

31 Quantitative Data Analysis
Descriptive statistics (dispersion) Pattern recognition Nonparametric within case comparison (EOC)


33 Study #1: Exploring the Feasiblity of VOCAs with Head and Neck Cancer Patients Following Surgery
MB. Happ1 S. Kagan2 T. Roesch1 E. Holmes1 1 University of Pittsburgh School of Nursing 2 University of Pennsylvania School of Nursing Funding: ONS Foundation/OrthoBiotech

34 Head & Neck Sample (n=10) 7 men, 3 women all Caucasian 5 MessageMate
5 DynaMyte

35 Observation & Interview
Observations: = 66 Communication Events = 50 (75.8%) Formal Interviews: = 9 Patient = 8 Nurse = 1

36 Characteristics (n=10) Ages: 45-82 yrs (57.1+12.8)
Education: yrs ( ) Computer Use: 7* *minimal level = 3/7

37 Procedures: Brachytherapy 2 Laryngectomy 8

38 Characteristics (cont).
Days w/ device: ( ) Post-op days prior to device: ( ) APACHE III: ( )

39 Neuromotor Characteristics
+ Motor Screen Tasks = 10 + Write legibly = 10 + Narcotics/sedation = 35/50 (70%)

40 Usage Patterns • VOCAs were used by some of the post surgical patients
- some required extensive assistance, whereas others required limited or no assistance • Other modalities were used as well -Writing - Gesture - Mouthing Words - Head Nods

41 Other findings Of the observed communication events in which patients utilized the VOCA, patients initiated more frequently than a historical (no-intervention) group. a slight increase in ease of communication was observed in the VOCA group when compared with a historical (no-intervention) group.

42 Novel Scenarios in which VOCAS were used
Cardiology evaluation Telephone usage

43 What were the barriers to device use?
device out-of-reach upper extremity & neck wounds blurred vision insufficient staff training in use patient preference for writing or other method

44 Message Content Comfort needs (pain, thirst, suction)
Questions about home & family “I love you”  Questions about tests and condition Phone conversations

45 Characteristics of the head and neck patient population that may have been associated with successful AAC device use: All were able to write All were liberated from ventilator Voicelessness was expected More independence

46 Case Study

47 “Tim” 46 year old Caucasian male
S/P Total laryngectomy & tooth extraction No prior history of intubation and mechanical ventilation No significant past medical history

48 “Tim” High school graduate Previous personal computer use
Vision corrected with eyeglasses Right hand dominance

49 “Tim” Motor screening tasks APACHE score = 29
Glasgow Coma Scale (GCS) = 15

50 Enrollment Immediate post operative phase
Transferred from Medical Intensive Care Unit (MICU) to Head and Neck ICU Patient appeared withdrawn Deferred until third post operative day “just don’t feel like it” No device training prior to study enrollment

51 Device Set Up Device options
Message Mate- simple, smaller message capacity DynaMyte- larger capacity, multi-level message display At bedside Duration ~1.5 hours Initial method of communication Writing/Gestures Device features of the DynaMyte and Message Mate were reviewed with Tim. He was given the option to select which device to utilize. Tim chose the DynaMyte. Tim expressed that he had more freedom with this larger message capacity device then the Message Mate.

52 Tim’s Requests Voice selection Message deletions “Yes/No”
“What time is it?” Message Additions “Hello” & “Good-bye”

53 Tim’s Requests Icon/Message change Performed at bedside
Requested by patient and/or family During entire enrollment period Affect change

54 Observation of Communication Events (OCE’s)
7 OCE’s from 5 study days Narcotic analgesia 5/7 OCE’s Additional non-AAC methods Head Nods Hand Gestures

55 Tim’s AAC Use Most utilized mode Keyboard feature
Utilized bilateral hands predominantly index fingers and thumb 6 available “pop-up” icons with additional methods Effective navigation

56 General Interactions with AAC Use
Convey feelings to nurse Pain Anxiety Establishing need for suctioning Requesting assistance in bathing Communication with RN’s, MD’s, family Typed “help me clean up”

57 Connection with Others
Aspects of AAC Use Positive Negative Ownership Time Consuming Sense of Control Unfamiliarity Connection with Others Use of space

58 Feedback Tim “I can say everything I want to say right now through typing [VOCA] and writing.” “I am satisfied with the way I communicate in the hospital.” Tim’s Sister “Patients need this device until prosthesis is in place. It is a great help.”

59 Practical Challenges Patient lost access to the device when he transferred off of the Head and Neck Unit (to Cardiology) Expensive Nursing, Physician, Clinician unfamiliarity Battery back up Infection control issue -- how to keep the device sterile Discharge to home without device?

60 Tim Taught Us Communication method needs to be customized for each patient Options for changes/deletions of various messages at all times Once a method is established, it is difficult to change or add another method

61 Results of this exploratory study will be submitted for publication….
• Stay tuned…you will be able to access more specific data after the manuscript has been accepted to a peer-reviewed journal.

62 Part III Pilot Study #2 -- Medical Intensive Care Unit (MICU)

63 Exploring the Feasiblity of VOCAs with Nonspeaking ICU Patients
M.B. Happ, PhD T. K. Roesch, BSN

64 MICU Sample (n=11) 15 patients identified 11 participated (73%)
7 men, 4 women 10 Caucasian

65 Observation & Interview
Observations: = 49 Communication Events = 41 (83.7%) Formal Interviews: = 14 Patient = 8 Family = 3 Clinician = 3

66 Characteristics (n=11) Ages: 20-72 yrs (45.5+16)
Education: yrs (13+1.9)* Computer Use: 6 *MR patient excluded from mean

67 Characteristics Intubation: Tracheostomy: 4 Oral ET tube: 7
Primary Medical Dx: Pneumonia/ARDS/Sepsis 7 Lung CA COPD Subglottic Stenosis 1 SCI

68 Characteristics (cont).
Days w/ device: 1-14 ( ) Ventilator Days: 1-44 ( ) APACHE III: ( )

69 Neuromotor Characteristics (n=11 Study Patients)
+ Motor Screen Tasks = 8 - Blind, quadriplegia - Quadriplegia Morbid Obesity + Write legibly = 3

70 Neuromotor Characteristics (n=49 observations)
Narcotic analgesia = 13 (26.5%) Anxiolytics/sedation = 22 (44.9%)

71 Usage Patterns Ventilated patients in the MICU used VOCA systems in over 1/4 of the observed communication events However, usage patterns ranged from “limited” to “required cues to use”. Most of the patients used more than one communication method Increased patient initiations were associated with availability of the VOCA

72 Observed VOCA Messages
“I love you”  = 9 FAQs (go home, restraints, breathing tube) = 4 Anxiety/worry/ fear = 4 Pain = 3 Comfort (thirst, position, cold) = 3 Family =1

73 Novel Scenarios in which MICU patients used VOCAs to communicate
Informed consent – to participate in research & diagnostic testing Semantically complex message building Patient initiated messages What is your religion? Is the house clean? I want my sister!

74 Quality Patient ratings of “Ease of Communication” increased significantly in the VOCA versus no VOCA (pretreatment) condition.

75 Anecdotal Reports of Satisfaction
That [VOCA] was a good thing there, it really helped me. (patient) It was easier to understand what she wanted. I can’t read sign language…I’m not a good guesser. (husband) I think it’s more complete and decisive. (RN)

76 Satisfaction When…they [patients] got the hang of this, they used it almost as a sole means of communication. They like this and they like the fact that people tend to respond to voice. And this was their voice. - RN People don’t communicate with people who don’t communicate back. - RN

77 Satisfaction Suggested Design Improvements Larger screens
Greater touch sensitivity Easier keyboard access (DynaMyte) Simplier – less expandable (DynaMyte) Realtime Tracking/Storage of Messages Backlighting (MessageMate)

78 Barriers poor positioning/out-of-reach UE weakness blurred vision
fluctuating cognition/attention deterioration in condition

79 Barriers Staff time constraints Lack of knowledge about device
Device complexity

80 Barriers It was easier for me to talk with him, and not have to pull out the device, because time is precious around here… Where he could get his point across to me with lip talking, it seemed to lessen the time… - RN

81 Partner Behaviors that Facilitated VOCA use
Cueing patients in selection of messages Repositioning patient or device Aids: glasses, hearing, access tools Patience with slow message generation Improved condition and UE strength

82 What we learned about AAC…
Start simple Basic instruction card SLP support Tech support Partner training

83 What we learned about AAC…
Use progressive, expandable techniques Capitalize on combined methods Cueing Consistency Repeat instructions

84 For further information and specific data from Study #2:
Keep an eye out for the following article: Happ, M.B., Roesch, T.K., & Garrett, K.L. (in press --expected 2004). Exploring the use of electronic VOCAs in the medical intensive care unit. Heart & Lung, 33, issue 2 or 3.

85 Part IV Introduction to the SPEACS Project

86 Time for a large-scale study…
A “large n” study across multiple ICU units Planned prospective design with 3 patient/nurse cohorts Treatment: A systematically designed AAC and basic communication intervention “package” implemented by nurses and an SLP Quantitative analysis of the INTERACTIONS between the nonspeaking patient AND the primary nurse caregiver

87 SPEACS: Study of Patient-Nurse Effectiveness with Assisted Communication Strategies

88 Multidisciplinary Research Team
Mary Beth Happ, Ph.D., R.N. Kathryn Garrett, Ph.D., CCC-SLP Susan Sereika, Ph.D. Elisabeth George, Ph.D., R.N. Michael Donahoe, M.D. Judith Tate, M.S., R.N. * * * * * * * * * * * School of Nursing University of Pittsburgh Duquesne University University of Pittsburgh Medical Center Expert consultants: Maria Connolly, B.S.,R.N. -- Loyola University Melanie Fried-Oken, Ph.D., CCC-SLP -- OHSU Neville Strumpf, Ph.D., R.N. -- U. of Penn

89 5-Year Funding ( ): National Institute of Child Health and Human Development (NICHHD) * * * * * * * * * * “Improving Communication with Nonspeaking Patients in the ICU” (R01-HD )

90 Overview Background and Rationale Research Questions & Study Aims
Research Design & Model Independent Variables: Description of 2-Phase Intervention Packages Procedures Dependent Variables/Data Collection Data Analysis Potential Challenges Invitation to Comment

91 Definition of Augmentative & Alternative Communication (AAC):
All communication methods that supplement natural speech including unaided (signing, vocalizations) or aided (writing, typing, electronic device) techniques - from Beukelman & Mirenda, 1998

92 Natural Approaches Mouthing words Writing Gesture


94 Typically, AAC devices are not available.
Natural, minimally aided communication strategies are the most frequently used by nonspeaking patients in the ICU. Typically, AAC devices are not available. Problems with relying on natural communication alone can include: Mouthing: Patients often cannot clearly mouth words around the endotracheal tube Writing: Paper/pen is not made available, the patient is illiterate, or upper extremity function is inadequate Gestures: Patients/nurses have no consistently shared gestural lexicon (Connolly, 1992) Opportunities: Patients do not receive adequate opportunities to initiate their own topics and messages (e.g., “Please find my reading glasses”) Rate: Message co-construction can be a slow process

95 Prosthetic Oral Approaches
Electrolarynx Tracheostomy one-way speaking valve

96 Aided Strategies: Low tech symbol boards/ direct selection

97 • synthesized or digitized
TM Electronic VOCAs • synthesized or digitized voice output • symbolized messages • multiple level option • scanning option DynaMyte Message Mate TM


99 Challenges AAC is not considered “customary care”
Nurses do not have easy access to AAC technologies Nurses do not receive training in their use Natural communication strategies and/or AAC technologies are not applied systematically to all conscious ICU patients Communication strategies are not individualized for specific patients Ongoing consultation about communication strategies typically is not available for nurses in the ICU

100 SPEACS: Study of Patient-Nurse Effectiveness with Assisted Communication Strategies

101 RQ/Specific Aim #1 What is the impact of two experimental interventions… Basic Communication Skills Training (BCST) for nurses AAC techniques and education + individualized SLP consultation (AAC-SLP) …on ease, quality, frequency and success of nurse-patient communication?

102 RQ/Specific Aim #2 How do interactions in the two communication intervention conditions (BCST and AAC-SLP) compare with those in a control (usual care) cohort?

103 Research Model

104 Interventions BCST AAC/SLP Voiceless Communication Patient Nurse
Process Voiceless Patient Nurse Outcomes Success Ease Quality Frequency Happ, M.B. & Garrett, K.L. (2003)

105 Our HYPOTHESIS: AAC-SLP > BCST > Control on: ease quality
frequency successfulness of nurse-patient communication interactions.

106 Research Design

107 Nonconcurrent Cohort Design with Repeated Measures
Year 1 Control T1 T2 T3 T4 Year 2 BCST X1T1 T2 T3 T4 Year 3 AAC-SLP X2T1 T2 T3 T4

108 2 Settings Medical ICU Cardiothoracic ICU

109 Independent Variables

110 Condition 1 - Usual Treatment
No specific communication training for nurses Communication interaction and intervention at the discretion of the patient or untrained nurses

111 Condition 2 -- BCST Training for nurses in basic communication skills prior to data collection Delivery: 2 hour inservice (instruction & roleplay) with SLP <2 months prior to data collection Website consistently available

112 Sample Basic Communication Skills
Approach patient Alert patient (“George…”) Tag yes/no questions (“Yes…or No?”) Provide auditory or written choices Ask open-ended questions when appropriate (“Tell me what’s on your mind.”) Instruct patients to use specific natural modalities if they do not initiate Show me one of the gestures we talked about. Write it for me. Can you mouth the words more clearly? Interpret utterances/mirror gestures

113 Condition 3 -- AAC + SLP Incorporates basic communication skills training SLP also works with nurse to develop individualized communication intervention plan for each patient. SLP also sets up AAC technologies, conducts message inventory, teaches patient, and trains nurse as appropriate SLP is available on an ongoing basis to consult with nurse about communication

114 Nurse Sample (quasi-random selection)
5 RNs/unit = 10 RNs x 3 phases = 30 RNs RN Entry Criteria: 1-year critical care experience Full-time staff, not permanent night Selected from pool of volunteers

115 Patient Sample 3 pts/RN = 30 pts x 3 phases = 90 patients
Patient Entry Criteria: Respiratory intubation Likely to remain intubated for a min of 48 hrs Understand English Glasgow Coma Scale > 13 Exclusion : Premorbid inability to communicate verbally or nonverbally (a score of <3 on the NOMS cognition, expressive, and receptive language subscales Delirium or limited movement OK

116 Dependent Variables

117 Data Sources Transcriptions of videorecorded nurse-patient interactions 3 minute segments -- 2x/day for 2 days for each nurse/patient dyad Observer ratings Field Notes Clinical record/chart

118 Videotapes of the 2-minute nurse/patient interactions will be transcribed and coded for the following variables: How frequently did the patient initiate communication? With which modality? How many of the nurse-patient communication exchanges resulted in successful message communication? How many breakdowns occurred? How many were successfully repaired? How often did the nurse demonstrate behaviors that facilitated communication? What was the function of the message?

119 Observer Ratings of Ease of Communication

120 Field Notes will also be compiled for qualitative analysis of:
Setting variables Topics Affect Unusual circumstances Presence of restraints Patient’s cognitive status Etc.

121 Data Sample 360 observations 4 observations/pt x 30 pts/phase
= 120 observations/phase x 3 phases 360 observations

122 Covariates Will specific patient or nurse variables explain/predict patterns in the data?

123 Patient Co-variates Gender Type of ICU Premorbid communication ability Measured by subscales of the NOMS Severity of Illness (APACHE) Length of Intubation prior to study enrollment Degree of Agitation (CAM-ICU) Degree of Sedation (RASS) Motor Ability (Lowenstein)

124 Nurse Co-variates Total nurse contact time with patient Time elapsed since training Critical care experience

125 Level of Consciousness Time Elapsed Since Training
Interventions BCST AAC/SLP Voiceless Patient Communication Process Nurse Level of Consciousness Illness Severity Communication Fx Motor Fx Nurse Contact Time Time Elapsed Since Training Outcomes Success Quality Ease Frequency

126 Data Analysis (S.S.) Exploratory data analysis
Hierarchical generalized linear modeling (HGLM) Linear contrasts based on hypotheses Model assessment (i.e., residual analysis and evaluation of outlier/ influential observations)

127 Potential Problems & Solutions
Brief ICU stays/2 day data collection period Variable nurse scheduling/ day nurses only, request same patient Fluctuation in patient condition/ track delirium and severity of illness as a co:variate Diffusion of the intervention/ assess in 2 ICUs, use 3 separate cohorts Measurement intrusiveness and complexity/ extra effort Is 2 days enough time to develop an effective communication intervention?/ oh well -- it represents the real life challenge!

128 Our timeline January 2004: Final Instrument Development & Pilot Testing of Procedures March 2004: Nurse/Patient enrollment for Usual Care Condition March 2005: Begin BCST Condition January 2006: Begin AAC-SLP Condition January 2007: Data Analysis July 2008: Complete Data Summarization

129 Questions and Comments from the Audience

130 Handouts Please cite information from this presentation as follows: ****** Correspondence: Mary Beth Happ, Ph.D., R.N. University of Pittsburgh Kathryn Garrett, Ph.D., CCC-SLP Duquesne University

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