What is New in Communication Aids for Critical Care Patients? - Joanne Kendall Advanced Specialist Speech and Language Therapist Neurosciences ...
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What is New in
Communication Aids for
Critical Care Patients?
Joanne Kendall
Advanced Specialist Speech and Language Therapist
Neurosciences Critical Care Unit
joanne.kendall@addenbrookes.nhs.uk
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Communication Difficulties in ICU
• Aphasia / dysphasia – language impairment
• Anarthria / dysarthria – motor weakness
• Aphonia / dysphonia – voice quality
• Dyspraxia – motor programming
• Cognitive-communication impairment
• Maxillofacial injuries or head & neck surgery
**Presence of ETT or tracheostomy
tube**
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Consequences of Communication Difficulties
• Anger (Khalaila et al. 2011)
• Frustration
• Fear (Khalaila et al. 2011)
• Low mood
• Withdrawal
• Reduced participation in rehabilitation
• Psychoemotional distress (Khalaila et al. 2011)
• Patient Experience “Like a prison” “powerless” (Magnus and
Turkington 2006)
• Increased length of stay (Ahrens et al. 2003, Lilly et al.2003)
• Increased mortality(Ahrens et al. 2003, Lilly et al.2003)
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Augmentative and
Alternative
Communication
(AAC)
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Assessment 1. Identify the needs of the individual: o Everyday needs, e.g. pain, suction o Decision making and participation in future care o Patient-family interactions 2. Consider nature of condition: o Temporary – short term, quick and easy solution o Static – longer-term solution o Degenerative – meet changing needs of patient 3. Assess their current level of function: o Cognition o Language o Upper limb function o Mobility Innovation and excellence in health and care
Factors to consider
• Medical instability • Reduced mobility or
• Inconsistency or movement
variability • Positioning and tone
• Level of alertness • Vision
• Hearing
• Fatigue
• Psychological well being
• Confusion or delirium • Familiarity with
• Cognitive impairment, technology
e.g. memory, attention, • Reliability of equipment
orientation • Obtaining funding
• Language impairment, • Access to the specialist
e.g. comprehension, word support or resources
finding, spelling, reading
• Literacy skills
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4 groups to help identify appropriate
communication methods:
1. Cognitively intact and motor intact, e.g.
respiratory patients
2. Cognitively intact and motor impaired, e.g.
SCI, GBS, MND
3. Cognitively impaired and motor intact, e.g.
ICU delirium, dementia, possibly TBI
4. Cognitively impaired and motor impaired, e.g.
TBI, CVA
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1. Cognitively Intact and Motor Intact • Mouthing • Writing – pen and paper or small whiteboard • Alphabet boards • Basic needs chart – written list of words • Finger spelling, air writing or gesture • Electrolarynx • Speech generating devices Innovation and excellence in health and care
Electrolayrnx • Oral communication method – quick, easy and effective • Robotic sounding vocal quality • Need intact oromotor strength for articulation • Can be difficult to position around trache • Not suitable for ETT Innovation and excellence in health and care
Speech Generating Devices
• Traditionally high cost = poor
availability
• Lightwriter
• Introduction of tablet
computers improving access,
e.g. Ipad
• Apps to download depending
on if Apple, Android or
Windows device
• Apps range in function from
pictures / basic needs to
keyboard text-to-speech
• Prices range from free - £199
• Website – appsforaac
Innovation and excellence in health and careIpad or other Tablet Devices • Consider: – Security – Protection – heavy duty case – Mounting options – Choice of apps Innovation and excellence in health and care
2. Cognitively Intact and Motor
Impaired
• Communication boards with orthotic aids or types of
stylus
• Partner assisted scanning, i.e. basic needs or alphabet
chart
http://www.youtube.com/watch?v=FGQapTlrsR4
• Call bells
• Complex speech generating devices – switch
activated scanning
• Eye gaze
Innovation and excellence in health and careCall Bells • Basic level of communication • Gaining staff attention • Helps to reassure patients and reduce anxiety • Need other systems in place to further communicate Innovation and excellence in health and care
Complex Speech Generating
Devices
• Communicate whole messages
• Usually an option for spelling
• Voice output
• Modifications i.e. size of square,
activation, pressure, dwell
• Switch activated scanning
• Multiple trials and opportunities
• Cognitively challenging
• Time consuming to set up
• Long ICU stay
• PredicAble and proloquo2go apps
Innovation and excellence in health and careEye Gaze • Low tech: – Yes/No – Etran frame – Speakbook • High tech: – Tobii eye gaze system – PCEye-Go Innovation and excellence in health and care
3. Cognitively Impaired and Motor
Intact
• Pictorial or text-based communication boards
• Written choices
• Gesture
• Simple speech generating devices e.g. basic needs
• Simple in design
• Limited in content
• Intuitive to use
Innovation and excellence in health and care4. Cognitively Impaired and Motor
Impaired
• Yes/No questions
– Check reliability
– Establish consistent and meaningful method to
respond
– Avoid blinking if at all possible
• Simplified partner assisted scanning
– Limited choice of 2 or 3
– Pictures or objects to aid comprehension
• Modification of conversation partner, i.e. us!, to maximise
and facilitate communication
Innovation and excellence in health and careGeneral Communication Strategies
• To help message in: • To help message out:
– Reduce background noise – Allow time to respond
– Reduce distractions – Involve patients in conversations and
– Gain patients’ attention first decisions
– Avoid too many people in a – Identify topic of conversation first, i.e. is
conversation at one time it about you?, is it something you
– Ensure hearing aids are in and glasses need?
are on (if needed) – Ask yes / no questions, i.e. are you in
– One message at a time pain?
– Try to ask closed questions or give
– Use key words
choices, i.e. do you want to sit up and
– Use context or visual cues, i.e. show lie down?
the patient
– Write down choices
– Use gesture, facial expression and
make eye contact – Encourage use of gesture, writing,
drawing, objects, pictures,
– Try writing down key words
– Acknowledge any form of
– Avoid changing topic of conversation communication including frustration
quickly
– Recap and check you have understood
each other
Innovation and excellence in health and careLow Tech vs High Tech
• Low tech: • High tech:
– Quick – More appealing
– Easy – Voice output
– Accessible – Individualize
– Cheap – Predicts
– Portable
Innovation and excellence in health and careCase Presentation • Multiple CVAs • ETT, nil sedation • Partially ‘locked-in’ • SLT assessment of communication • Established reliable yes/no via hand squeeze • Patient discussion around wishes for future care with SLT and consultant • Cognitively intact but severely motor impaired • Only could access yes / no • Patient able to make informed decision and chose full active treatment Innovation and excellence in health and care
Key Messages!
• Optimise use of speaking valves
• One method DOES NOT suit everyone
• Individualised strategies and AAC support
• Establish a consistent method
• Ensure meaningful and functional
• Check comprehension and cognition
• If not sure what works, then give it a go!
• Clearly handover what works and what doesn’t
• Adapt with changing needs of patient
• High tech not always better
Innovation and excellence in health and careReferences
• Ahrens T, Yancey V, Kollef M. Improving family communications at the end of life:
implications for length of stay in the intensive care unit and resource use. Am J Crit
Care 2003;12(4):317—23.
• Khalaila R.,Zbidat W.,Anwar K.,Bayya A.,Linton D.M.,Sviri S. Communication
difficulties and psychoemotional distress in patients receiving mechanical ventilation.
American Journal of Critical Care, Nov 2011, vol./is. 20/6(470-479), 1062-3264 (01
Nov 2011)
• Lilly CM, Sonna LA, Haley KJ, Massaro AF. Intensive communication: four-year
follow-up from a clinical practice study. Crit Care Med 2003;31(5 suppl.):S394—9.
• Magnus VS and Turkington L. Communication interaction in ICU—–Patient and staff
experiences and perceptions. Intensive and Critical Care Nursing (2006) 22, 167—
180
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