AAC in the ICU: Critical Issues and Preliminary Research

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 2003 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 (Menzel, 1998) • 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 … • Patientcharacteristics(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. 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)2 L.. Menzel (1998).

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

24. 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. 1 NAUSEA Say SICK I’m OK Pain shot PAIN NOT OK MEDICINE 2 Back Space HOT COLD SAD HAPPY ANGRY AFRAID TIRED HUNGRY 3 Clear MOUTH CARE TV BATH DRINK BEDPAN SUCTION MUSIC GLASSES 4 I LOVE YOU Repeat WHY? WHERE? NURSE FAMILY HOME HEAR TIME DOCTOR MessageMateTM MY MOUTH CAT DOG

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

29. pole swivelarm

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)

32. RESULTS

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: 12-20 yrs (13.5+2.9) • Computer Use: 7* *minimal level = 3/7

37. Procedures: • Brachytherapy 2 • Laryngectomy 8

38. Characteristics(cont). • Days w/ device: 3-24 (9.1+ 6.2) • Post-op days prior to device: 1-6 (1.9+.1.6) • APACHE III: 5-53 (27.1+13.2)

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