Presentation on theme: "AAC in the ICU: Critical Issues and Preliminary Research"— Presentation transcript:
1AAC in the ICU: Critical Issues and Preliminary Research Mary Beth Happ, Ph.D., R.N.Kathryn Garrett, Ph.D., CCC-SLPTricia Roesch, B.S.N., R.N.* * * * * * * * * * * * * * *School of Nursing University of PittsburghDuquesne University, Pittsburgh PAASHA Convention November Chicago
3Overview Part I: Literature Review Part II: Feasibility study of electronicVOCAs in the Surgical Otolaryngology Unitand Case ExamplePart III: Feasibility study of electronicVOCAs in the Medical Intensive Care UnitPart IV: NIH-funded Intervention Study The SPEACS Project
4Note:Please refer to the Microsoft Word document by the same title for a narrative version of this presentationThe Word document will also contain the reference list.
6Descriptive reports of the mechanical ventilation experience in the ICU Patients experience:FEARPANICSTRESSAs a result of the inability to speak
7Nurse-Patient communication in ICU: Brief (< 5 min), task-oriented, commands & reassurances during physical care.
8Patients typically communicate with nods, gestures, and mouthing words.
9ICU interactions do NOT usually involve communication of the patient’s ideas,patient’s initiation of messages or elaboration.
10Communication difficulty with mechanically ventilated (MV) patients - related to illness severity, anger(Menzel, 1998)Greater difficulty communicating with family than with nursesUnder-recognition & high levels of pain reported in MV patients (SUPPORT studies)RNs/MDs more likely to communicate with patients who are more responsive.
11Statement 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)
12Clinical case reportsIntroducing 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)
13A need exists for:Specific data on communication interventions for nonspeaking, intensive care unit patientsAnalysis of high tech versus low tech interventionsPerceptual, qualitative, and quantitative analysesComparisons between different ICU populationsUsage data as well as interactional data
17What 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?
18Complementary Design QUAL + quan No hypotheses Purposive-theoretical samplingSmall samplesMorgan, 1998
19University of Pittsburgh Medical Center - Otolaryngology surgical unit Settings:University of Pittsburgh Medical Center- Otolaryngology surgical unit- Medical ICU – 20 bedsEntry Criteria:Respiratory intubationResponsive to verbal stimuliFollows commands consistentlyInitial Cognitive-Linguistic Screen** Dowden, Honsinger & Beukelman, 1986
22Data Collection Enrollment Pre-test Ease of Communication Scale2 APACHE, Motor Screen1DailyObservations (20min)Chart ReviewExtubationPost-test Ease of Communication Scale2Exit Interviews1. P. Dowden et al. (1986) L.. Menzel (1998).
23Head and Neck Surgical Unit Part IIPilot Research:Head and Neck Surgical Unit
24Funding: AACN/ Sigma Theta Tau ONS Foundation/ OrthoBiotech Mentorship/Consultation:Dr. Richard Hurtig, University of IowaStephanie Williams, SLP, Dynavox Systems, IncFunding: AACN/ Sigma Theta Tau ONS Foundation/ OrthoBiotechEquipment donations:DynaVox Systems, Inc.WordsPlus, Inc.AbleNet
27MessageMateTM 1 2 3 4 SICK COLD TV Say PAIN Back Space Clear BATH NAUSEASaySICKI’m OKPain shotPAINNOT OKMEDICINE2BackSpaceHOTCOLDSADHAPPYANGRYHUNGRYAFRAIDTIRED3ClearMOUTHCARETVBATHSUCTIONDRINKBEDPANMUSICGLASSES4ILOVEYOURepeatWHY?WHERE?NURSEDOCTORFAMILYHOMEHEARTIMEMessageMateTMMYMOUTHCATDOG
28Basic Messages Pain Shortness of Breath Suction Help! Hot/Cold Home/FamilyAnxiety/Worry
33Study #1: Exploring the Feasiblity of VOCAs with Head and Neck Cancer Patients Following Surgery MB. Happ1S. Kagan2T. Roesch1E. Holmes11 University of Pittsburgh School of Nursing2 University of Pennsylvania School of NursingFunding: ONS Foundation/OrthoBiotech
34Head & Neck Sample (n=10) 7 men, 3 women all Caucasian 5 MessageMate 5 DynaMyte
40Usage 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
41Other findingsOf 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.
42Novel Scenarios in which VOCAS were used Cardiology evaluationTelephone usage
43What were the barriers to device use? device out-of-reachupper extremity & neck woundsblurred visioninsufficient staff training in usepatient preference for writing or other method
44Message Content Comfort needs (pain, thirst, suction) Questions about home & family“I love you” Questions about tests and conditionPhone conversations
45Characteristics of the head and neck patient population that may have been associated with successful AAC device use:All were able to writeAll were liberated from ventilatorVoicelessness was expectedMore independence
47“Tim” 46 year old Caucasian male S/P Total laryngectomy & tooth extractionNo prior history of intubation and mechanical ventilationNo significant past medical history
48“Tim” High school graduate Previous personal computer use Vision corrected with eyeglassesRight hand dominance
49“Tim” Motor screening tasks APACHE score = 29 Glasgow Coma Scale (GCS) = 15
50Enrollment Immediate post operative phase Transferred from Medical Intensive Care Unit (MICU) to Head and Neck ICUPatient appeared withdrawnDeferred until third post operative day“just don’t feel like it”No device training prior to study enrollment
51Device Set Up Device options Message Mate- simple, smaller message capacityDynaMyte- larger capacity, multi-level message displayAt bedsideDuration ~1.5 hoursInitial method of communicationWriting/GesturesDevice 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.
52Tim’s Requests Voice selection Message deletions “Yes/No” “What time is it?”Message Additions“Hello” & “Good-bye”
53Tim’s Requests Icon/Message change Performed at bedside Requested by patient and/or familyDuring entire enrollment periodAffect change
54Observation of Communication Events (OCE’s) 7 OCE’s from 5 study daysNarcotic analgesia5/7 OCE’sAdditional non-AAC methodsHead NodsHand Gestures
55Tim’s AAC Use Most utilized mode Keyboard feature Utilized bilateral hands predominantly index fingers and thumb6 available “pop-up” icons with additional methodsEffective navigation
56General Interactions with AAC Use Convey feelings to nursePainAnxietyEstablishing need for suctioningRequesting assistance in bathingCommunication with RN’s, MD’s, familyTyped “help me clean up”
57Connection with Others Aspects of AAC UsePositiveNegativeOwnershipTime ConsumingSense of ControlUnfamiliarityConnection with OthersUse of space
58FeedbackTim“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.”
59Practical ChallengesPatient lost access to the device when he transferred off of the Head and Neck Unit (to Cardiology)ExpensiveNursing, Physician, Clinician unfamiliarityBattery back upInfection control issue -- how to keep the device sterileDischarge to home without device?
60Tim Taught UsCommunication method needs to be customized for each patientOptions for changes/deletions of various messages at all timesOnce a method is established, it is difficult to change or add another method
61Results 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.
62Part IIIPilot Study #2 -- Medical Intensive Care Unit (MICU)
63Exploring the Feasiblity of VOCAs with Nonspeaking ICU Patients M.B. Happ, PhDT. K. Roesch, BSN
71Usage PatternsVentilated patients in the MICU used VOCA systems in over 1/4 of the observed communication eventsHowever, usage patterns ranged from “limited” to “required cues to use”.Most of the patients used more than one communication methodIncreased patient initiations were associated with availability of the VOCA
73Novel Scenarios in which MICU patients used VOCAs to communicate Informed consent – to participate in research & diagnostic testingSemantically complex message buildingPatient initiated messagesWhat is your religion?Is the house clean?I want my sister!
74QualityPatient ratings of “Ease of Communication” increased significantly in the VOCA versus no VOCA (pretreatment) condition.
75Anecdotal 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)
76SatisfactionWhen…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. - RNPeople don’t communicate with people who don’t communicate back. - RN
77Satisfaction Suggested Design Improvements Larger screens Greater touch sensitivityEasier keyboard access (DynaMyte)Simplier – less expandable (DynaMyte)Realtime Tracking/Storage of MessagesBacklighting (MessageMate)
79Barriers Staff time constraints Lack of knowledge about device Device complexity
80BarriersIt 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
81Partner Behaviors that Facilitated VOCA use Cueing patients in selection of messagesRepositioning patient or deviceAids: glasses, hearing, access toolsPatience with slow message generationImproved condition and UE strength
82What we learned about AAC… Start simpleBasic instruction cardSLP supportTech supportPartner training
83What we learned about AAC… Use progressive, expandable techniquesCapitalize on combined methodsCueingConsistencyRepeat instructions
84For 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.
86Time for a large-scale study… A “large n” study across multiple ICU unitsPlanned prospective design with 3 patient/nurse cohortsTreatment: A systematically designed AAC and basic communication intervention “package” implemented by nurses and an SLPQuantitative analysis of the INTERACTIONS between the nonspeaking patient AND the primary nurse caregiver
87SPEACS:Study of Patient-Nurse Effectiveness with Assisted Communication Strategies
88Multidisciplinary Research Team Mary Beth Happ, Ph.D., R.N.Kathryn Garrett, Ph.D., CCC-SLPSusan Sereika, Ph.D.Elisabeth George, Ph.D., R.N.Michael Donahoe, M.D.Judith Tate, M.S., R.N.* * * * * * * * * * *School of Nursing University of PittsburghDuquesne UniversityUniversity of Pittsburgh Medical CenterExpert consultants:Maria Connolly, B.S.,R.N. -- Loyola UniversityMelanie Fried-Oken, Ph.D., CCC-SLP -- OHSUNeville Strumpf, Ph.D., R.N. -- U. of Penn
895-Year Funding ( ): National Institute of Child Health and Human Development (NICHHD) * * * * * * * * * * “Improving Communication with Nonspeaking Patients in the ICU” (R01-HD )
90Overview Background and Rationale Research Questions & Study Aims Research Design & ModelIndependent Variables: Description of 2-Phase Intervention PackagesProceduresDependent Variables/Data CollectionData AnalysisPotential ChallengesInvitation to Comment
91Definition 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
94Typically, 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 tubeWriting: Paper/pen is not made available, the patient is illiterate, or upper extremity function is inadequateGestures: 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
99Challenges AAC is not considered “customary care” Nurses do not have easy access to AAC technologiesNurses do not receive training in their useNatural communication strategies and/or AAC technologies are not applied systematically to all conscious ICU patientsCommunication strategies are not individualized for specific patientsOngoing consultation about communication strategies typically is not available for nurses in the ICU
100SPEACS:Study of Patient-Nurse Effectiveness with Assisted Communication Strategies
101RQ/Specific Aim #1What is the impact of two experimental interventions…Basic Communication Skills Training (BCST) for nursesAAC techniques and education + individualized SLP consultation(AAC-SLP)…on ease, quality, frequency and success of nurse-patient communication?
102RQ/Specific Aim #2How do interactions in the two communication intervention conditions (BCST and AAC-SLP) compare with those in a control (usual care) cohort?
110Condition 1 - Usual Treatment No specific communication training for nursesCommunication interaction and intervention at the discretion of the patient or untrained nurses
111Condition 2 -- BCSTTraining for nurses in basic communication skills prior to data collectionDelivery:2 hour inservice (instruction & roleplay) with SLP <2 months prior to data collectionWebsite consistently available
112Sample Basic Communication Skills Approach patientAlert patient (“George…”)Tag yes/no questions (“Yes…or No?”)Provide auditory or written choicesAsk open-ended questions when appropriate (“Tell me what’s on your mind.”)Instruct patients to use specific natural modalities if they do not initiateShow me one of the gestures we talked about.Write it for me.Can you mouth the words more clearly?Interpret utterances/mirror gestures
113Condition 3 -- AAC + SLPIncorporates basic communication skills trainingSLP 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 appropriateSLP is available on an ongoing basis to consult with nurse about communication
114Nurse Sample (quasi-random selection) 5 RNs/unit = 10 RNs x 3 phases= 30 RNsRN Entry Criteria:1-year critical care experienceFull-time staff, not permanent nightSelected from pool of volunteers
115Patient Sample 3 pts/RN = 30 pts x 3 phases = 90 patients Patient Entry Criteria:Respiratory intubationLikely to remain intubated for a min of 48 hrsUnderstand EnglishGlasgow Coma Scale > 13Exclusion :Premorbid inability to communicate verbally or nonverbally (a score of <3 on the NOMS cognition, expressive, and receptive language subscalesDelirium or limited movement OK
117Data SourcesTranscriptions of videorecorded nurse-patient interactions3 minute segments -- 2x/day for 2 days for each nurse/patient dyadObserver ratingsField NotesClinical record/chart
118Videotapes 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?
122CovariatesWill specific patient or nurse variables explain/predict patterns in the data?
123Patient Co-variatesGenderType of ICUPremorbid communication abilityMeasured by subscales of the NOMSSeverity of Illness (APACHE)Length of Intubation prior to study enrollmentDegree of Agitation (CAM-ICU)Degree of Sedation (RASS)Motor Ability (Lowenstein)
124Nurse Co-variatesTotal nurse contact time with patientTime elapsed since trainingCritical care experience
125Level of Consciousness Time Elapsed Since Training InterventionsBCSTAAC/SLPVoicelessPatientCommunicationProcessNurseLevel of ConsciousnessIllness SeverityCommunication FxMotor FxNurse Contact TimeTime Elapsed Since TrainingOutcomesSuccessQualityEaseFrequency
126Data Analysis (S.S.) Exploratory data analysis Hierarchical generalized linear modeling (HGLM)Linear contrasts based on hypothesesModel assessment (i.e., residual analysis and evaluation of outlier/ influential observations)
127Potential Problems & Solutions Brief ICU stays/2 day data collection periodVariable nurse scheduling/ day nurses only, request same patientFluctuation in patient condition/ track delirium and severity of illness as a co:variateDiffusion of the intervention/ assess in 2 ICUs, use 3 separate cohortsMeasurement intrusiveness and complexity/ extra effortIs 2 days enough time to develop an effective communication intervention?/ oh well -- it represents the real life challenge!
128Our timelineJanuary 2004: Final Instrument Development & Pilot Testing of ProceduresMarch 2004: Nurse/Patient enrollment for Usual Care ConditionMarch 2005: Begin BCST ConditionJanuary 2006: Begin AAC-SLP ConditionJanuary 2007: Data AnalysisJuly 2008: Complete Data Summarization