Voxello’s mission directly addresses the communication barriers in the ICU that the Covid19 pandemic has brought to everyone’s attention (www.voxello.com).
Imagine yourself waking up in an intensive care unit and on a ventilator. You feel awful and because you are hooked up to a ventilator you are unable to speak. You are alone as your family and friends are not permitted into the hospital because of Covid19 precautions. You are surrounded by doctors, nurses and respiratory therapists who are wearing masks and other protective equipment that makes it difficult for you to hear and understand what they are telling you. You have lots of questions about your condition. You want to have a role in critical medical decision making. You want to communicate with your family and know how they are doing. You are scared and not being able to speak and effectively communicate with your healthcare providers is not only stressful but also impacts the care they can provide.
When patients are unable to communicate they are at a heightened risk of experiencing preventable adverse medical outcomes. It is essential that a patient be able to communicate that they are in pain or experiencing a novel symptom if we hope to reduce the risk of ventilator-associated pneumonia, pressure sores, and adverse reactions to medications or blood products. Measures of heart rate, blood pressure, and blood oxygen levels can tell us a lot about a patient’s state, but they cannot necessarily tell us what the source of the patient’s distress is. If a patient is agitated we naturally assume that it is related to the condition that landed them in the ICU.
We had an elderly patient at the University of Iowa Hospitals and Clinics who was intubated and on a ventilator in our ICU and was very agitated about something. The nurses tried to get the patient to write out what was bothering her, but her handwriting was illegible, so they began to ask her a series of yes/no questions. Was she in pain? Was she worried about her condition? This went on for a considerable amount of time and they were not getting any closer to figuring out what was bothering her. By happenstance, they landed up asking the patient some random questions totally unrelated to the condition that brought her to the hospital. It turned out that what she was so worried about was that she had taken some chicken out of the freezer and was worried that it was on her kitchen counter and would spoil. Throughout this whole process, the patient’s anxiety continued to increase to the point that the staff was considering having to sedate the patient. The minute the staff figured out what the patient was worried about and could address that, the patient’s anxiety was alleviated without medical intervention.
Colleagues working with a patient at the University of Wisconsin reported on a patient who was on a ventilator and would need to stay on the ventilator and so would need a tracheostomy. In order to get consent for the procedure, the medical staff was communicating with the patient by asking him yes/no questions. He repeatedly seemed to indicate that he did not want to have a tracheostomy. Luckily a speech-language pathologist was called in and provided the patient with some communication tools that would allow the patient to ask questions. It turned out that the patient definitely did want to be maintained on the ventilator. What he had been indicating in response to the yes/no questions was that he did not want to be awake during the procedure. Absent the intervention by the speech-language pathologist his initial responses would have been interpreted to mean that he wanted to be withdrawn from life support.
In spite of all the amazing advances in medicine, effective communication between the patient and health care providers remains a key to positive outcomes. We know that patients who are critically ill and in ICUs face significant barriers to communication. Covid19 precautions have only exacerbated the impact of such barriers. Being on mechanical ventilation makes it impossible for patients to speak. Personal protective equipment (PPE) makes it more difficult for patients to hear and understand what their caregivers are saying. It is critical to both diagnosis and to determining the impact of an intervention that a patient be able to communicate about pain and other symptoms. Likewise, it is critical that providers are able to effectively communicate in order to make a patient understand the condition, the intervention being recommended and what actions the patient should take. To make matters worse the current restrictions on visitors have also removed the support that family members and friends can provide. This forces patients to have to cope in isolation and adds to the burdens on their healthcare providers. All of this is even a greater challenge when providing care for patients with limited proficiency in the language spoken by their care providers.
Being in the ICU and on a ventilator produces significant stress and has been identified as a cause of post-ICU stress disorder syndrome akin to the PTSD seen in combat veterans. The stress on nurses and other healthcare providers who are caring for ICU patients has been well documented and has certainly been amplified by the added risks associated with treating patients with COVID19.
Meeting the challenge of overcoming communication barriers in this time of Covid19 is not necessarily going to require complex technology or a new skill set. We can learn from the best practices implemented in hospitals around the world. Speech-language pathologists (SLP) working in hospital settings have for years been providing a range of communication tools and strategies that have enabled critically ill patients to communicate and to more effectively participate in their care and in medical decision making. I have been working with a group of SLPs and other health providers around the country to put together a set of materials that can be freely downloaded and used in the ICUs to support patient-provider communication (www.patientprovidercommunication.org ). Since the Patient Provider Communication site has gone live, it has had over 57,,000-page views by individuals across the U.S. from 107 countries around the world.
No patient hospitalized with Covid19 should be cut off from effectively communicating with their caregivers. Simple communication tools will help patients and their caregivers overcome the physical and psychological stress we are hearing about every day as our healthcare system is severely challenged by the Covid19 pandemic.
Richard Hurtig, Ph.D.
About Dr. Hurtig
Richard Hurtig, Ph.D. is a Professor Emeritus in the department of Communication Sciences & Disorders at The University of Iowa and is a Fellow of the American Speech & Hearing Association. He directs the UI Assistive Devices Laboratory and is also a founder and the Chief Scientific Officer of Voxello. His research over a period of 30 years has included the development of assistive technologies for individuals with complex communication needs and the development of strategies to facilitate patient-provider communication for patients in acute care and for persons with ALS. His current efforts have been focused on the development of the noddle® and the noddle-chat communictaion app. This work has been supported in part by the National Institute of Nursing Research under Awards R43NR016406 and R44NR016406.