The Feasibility, Utility, and Safety of Communication Interventions With Mechanically Ventilated Intensive Care Unit Patients: A Systematic Review

Facilitators, barriers and acceptability of implementing a communication board in Sri Lankan intensive care units: A qualitative descriptive study

OBJECTIVES

To explore patients' and nurses' views of potential facilitators, barriers, and prospective acceptability of implementing a communication board in Sri Lankan intensive care units.

DESIGN

A qualitative, descriptive study.

RESEARCH METHODOLOGY

Eight patients who received mechanical ventilation and nine nurses who worked in adult medical and surgical intensive care units were purposively selected. Data were collected via audio-taped, semi-structured, face-to-face interviews in January/February 2023. Interview guide questions were informed by the knowledge-to-action framework and the theoretical framework of acceptability. Data were analysed using inductive and deductive content analysis. The 32-item checklist of the consolidated criteria for reporting qualitative research (COREQ) was used to ensure the quality of reporting.

SETTING

A 3,000 bed Sri Lankan teaching hospital with 18 intensive care units.

FINDINGS

Four categories reflecting patients' and nurses' anticipated use of the board were found. The first category described patients' and nurses' 'readiness to use the communication board' and their positive attitudes towards it. The second category focused on the 'potential benefits of the communication board', while the third category emphasised the 'individual patient characteristics' that should be taken into consideration when implementing communication boards. The final category described practical aspects related to 'integrating communication boards into routine practice'.

CONCLUSION

This study demonstrates communication boards may improve communication between ventilated patients and nurses, and they are acceptable to end users. Adopting these tools may be a pivotal step to enhancing patient-centred care in demanding intensive care settings.

IMPLICATIONS FOR CLINICAL PRACTICE

An inability to communicate effectively with ventilated intensive care patients creates negative experiences for both patients and nurses. Communication boards may act as a medium to better understand patients' needs during mechanical ventilation.Understanding patients' and nurses' views is beneficial when designing patient-centred communication interventions in intensive care units.

Exploring Communication Needs and Challenges in the Intensive Care Unit: A Survey Study From Providers' and Patients' Perspectives

PURPOSE

Effective communication between nonspeaking patients and providers is critical for the quality of care in intensive care units (ICUs). This study aims to evaluate perspectives of health care providers and nonspeaking patients on effective communication and communication barriers in the ICU.

METHOD

Qualitative and quantitative survey methodologies were employed to evaluate providers' and patients' perspectives on effective communication. Rating scales were utilized to measure patients' frustration levels and communication effectiveness. Open-ended questions were employed to reflect on barriers to communication in the ICU, instances of ineffective communication, and recommendations for enhancing effective communication.

RESULTS

The results of the study suggest that nonspeaking patients experienced high levels of frustration due to ineffective communication. However, the data reveal that access to appropriate augmentative and alternative communication (AAC) strategies and materials could help mitigate patients' frustration. Providers mainly communicated via asking yes/no questions, which largely limited the information patients conveyed, leading to frequent communication breakdowns. Providers expressed a desire to participate in training programs to utilize appropriate AAC strategies and promote effective communication.

CONCLUSIONS

This study provides preliminary survey results on perspectives of patients and providers on effective communication in the ICU. Both providers and patients reported experiencing challenges and frustration during their communication, due to barriers such as providers' insufficient training experience and lack of access to AAC materials. Skill training is warranted to promote effective patient-provider communication in intensive care settings.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.26339623.

Effectiveness, experience, and usability of low-technology augmentative and alternative communication in intensive care: A mixed-methods systematic review

BACKGROUND

Patients in the intensive care unit (ICU) are commonly on mechanical ventilation, either through endotracheal intubation or tracheostomy, which usually leaves them nonverbal. Low-technology augmentative and alternative communication (AAC) strategies are simple and effective ways to enhance communication between patients and their communication partners but are underutilised.

AIM

The aim of this study was to systematically review current evidence regarding the effectiveness, experience of use, and usability of low-technology AAC with nonverbal patients and their communication partners in the ICU.

METHODS

This review included quantitative, qualitative, and mixed-methods studies of adult ICU patients aged 18 or older who were nonverbal due to mechanical ventilation and their communication partners. Studies using low-technology AAC, such as communication boards and pen and paper, were included. Six databases were searched, and the review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A convergent segregated approach was used for data synthesis.

RESULTS

Thirty-two studies were included. Low-technology AAC improved patient satisfaction, facilitated communication, and met patients' physical and psychological needs. Communication boards with mixed content (e.g., pictures, words, and letters) were preferred but were used less frequently than unaided strategies due to patients' medical status, tool availability, and staff attitudes. Boards should be user-friendly, tailored, include pen/paper, and introduced preoperation to increase patient's comfort when using them postoperatively.

CONCLUSION

Existing evidence support low-technology AAC's efficacy in meeting patients' needs. Better usability hinges on proper implementation and addressing challenges. Further research is crucial for refining communication-board design, ensuring both user-friendliness and sophistication to cater to ICU patients' diverse needs.

REGISTRATION

The review protocol was registered in the International Prospective Register of Systematic Reviews, with registration number CRD42022331566.

Comparison of communication interfaces for mechanically ventilated patients in intensive care

OBJECTIVES

This study aimed to compare the use of a conventional low-tech communication board and a high-tech eye tracking device to improve communication effectiveness of mechanically ventilated patients in intensive care.

DESIGN

A prospective randomized crossover was conducted with a mixed method approach (quantitative primary method and qualitative complementary method) to compare the two technologically opposed communication interfaces.

SETTING

The mechanically ventilated patients were recruited from the general intensive care unit of the Marie Curie Civil Hospital (Charleroi University Hospital, Belgium).

MAIN OUTCOME MEASURES

The communication exchanges were assessed through effectiveness indicators covering the quantity of messages transmitted, success rate, patient satisfaction, communication content and difficulties of use.

RESULTS

The sample consisted of 44 mechanically ventilated patients, covering 88 communication exchanges. The intervention effects on the quantity of messages transmitted (two median messages per exchange for the board versus four median messages per exchange for the eye tracking, p < 0.0001), success rate (80 % for the board versus 100 % for the eye tracking, p < 0.05) and patient satisfaction (66 % "not satisfied", 32 % "satisfied" and 2 % "dissatisfied" for the board versus 52 % "satisfied" and 48 % "very satisfied" for the eye tracking, p < 0.0001) were significant. The communication content covered eight themes for the board compared to nine themes for the eye tracking and the use difficulties included four categories for the board as well as for the eye tracking.

CONCLUSION

The eye tracking device may further improve communication effectiveness of mechanically ventilated patients compared to the conventional communication board, both quantitatively and qualitatively.

IMPLICATIONS FOR CLINICAL PRACTICE

The implementation of high-tech communication devices based on eye tracking in intensive care practice can significantly contribute to patient-centered care by improving communication of mechanically ventilated patients.

Implementation of Above-Cuff Vocalization After Tracheostomy Is Feasible and Associated With Earlier Speech

PURPOSE

The purpose of this study was to assess the feasibility of hospital-wide implementation of an above-cuff vocalization (ACV) protocol using ACV-capable tracheostomy tubes and its impact on patient speech in four intensive care unit (ICU) patient populations.

METHOD

This research was an observational pre-post study that was conducted over a 26-month period and included 323 critically ill adult ICU patients who underwent tracheostomy in a 365-bed academic tertiary care hospital. ACV was assessed using a protocol developed by a multidisciplinary team. Presence of speech was defined as at least one comprehensible word spoken during a speech-language pathologist evaluation.

RESULTS

Median time-to-speech was 13 days (interquartile range [IQR]: 8-20 days) before the intervention, compared to 9 days (IQR: 6-16 days) after the intervention (p = .0017). In the pre-intervention group, 101 out of 167 (60.5%) patients achieved speech within 60 days, compared to 83 out of 133 (62.4%) patients in the post-intervention group (p = .12). Of the 83 patients who achieved speech in the post-intervention group, 24 (28.9%) did so via ACV, with the remainder using a speaking valve or digital occlusion. Of those 24 patients, seven did not progress to using a speaking valve within the follow-up period. The median number of speech days gained by using ACV was 8 (IQR: 5-18 days). ACV was successful in facilitating speech in 24 out of 29 (82.8%) patients trialed, with no major complications.

CONCLUSIONS

Routine implementation of ACV after tracheostomy is feasible, safe, and associated with earlier speech in a diverse population of critically ill patients. ACV is an important method to facilitate communication in patients requiring mechanical ventilation with tracheostomy cuff inflation.

Development, feasibility testing, and preliminary evaluation of the Communication with an Artificial airway Tool (CAT): Results of the Crit-CAT pilot study

BACKGROUND

A purpose-built outcome measure for assessing communication effectiveness in patients with an artificial airway is needed.

OBJECTIVES

The objective of this study was to develop the Communication with an Artificial airway Tool (CAT) and to test the feasibility and to preliminary evaluate the clinical metrics of the tool.

METHODS

Eligible patients with an artificial airway in the Intensive Care Unit were enrolled in the pilot study (Crit-CAT). The CAT was administered at least twice before and after the communication intervention. Item correlation analysis was performed. Participant and family member acceptability ratings and feedback were solicited. A qualitative thematic analysis was undertaken.

RESULTS

Fifteen patients with a mean age of 53 years (standard deviation [SD]: 19.26) were included. The clinician-reported scale was administered on 50 attempts (100%) with a mean completion time of 4.5 (SD: 0.77) minutes. The patient-reported scale was administered on 46 out of 49 attempts (94%) and took a mean of 1.5 (SD: 0.39) minutes to complete. The CAT was feasible for use in the Intensive Care Unit, with patients with either an endotracheal or tracheostomy tube, whilst receiving invasive mechanical ventilation or not, and while using either verbal or nonverbal modes of communication. Preliminary establishment of responsiveness, validity, and reliability was made. The tool was acceptable to participants and their family members.

CONCLUSION

The clinician-reported and patient-reported components of the study were feasible for use. The CAT has the potential to enable quantifiable comparison of communication interventions for patients with an artificial airway. Future research is required to determine external validity and reliability.

Augmentative and alternative communication tools for mechanically ventilated patients in intensive care units: A scoping review

OBJECTIVES

The aim of this scoping review was to understand the extent and type of evidence on augmentative and alternative communication tools used with mechanically ventilated patients in the intensive care unit.

REVIEW METHOD USED

This scoping review was conducted using Arksey and O'Malley's methodological framework, followed by PAGER (Patterns, Advances, Gaps, Evidence for practice and Research recommendations) framework to provide a structured approach to analysis of reviews.

DATA SOURCES

In December 2021, six electronic databases-CENTRAL, CINAHL, Embase, Medline (Ebscohost), PyscINFO, and Web of Science-were searched. Searches were supplemented with hand searching of reference lists of included studies.

REVIEW METHODS

Studies were selected according to inclusion and exclusion criteria. Full-text review was completed by two independent authors, with any disagreement resolved by consensus or with consultation with a third reviewer. A table was developed to extract key information from the eligible studies. The Mixed Methods Appraisal Tool and Supporting the Use of Research Evidence checklist were used to quality appraise the selected primary research and reviews, respectively.

RESULTS

Twenty-three studies (19 primary studies and four reviews) were included in the review. Findings highlighted five main patterns: (i) Co-designing of the augmentative and alternative communication tools; (ii) Patients' and healthcare professionals' training needs on augmentative and alternative communication tools; (iii) Implementation of validated communication assessment algorithms; (iv) Amalgamate several communication methods/approaches; (v) Technical competency required for high-technology augmentative and alternative communication tools.

CONCLUSION

Both low- and high-technology augmentative and alternative communication tools are widely used for mechanically ventilated patients in intensive care units, but there is a need for systematically assessing the communication needs and implementing communication interventions to promote meaningful patient-centred clinical outcomes.

Tracheostomy clinical practices and patient outcomes in three tertiary metropolitan hospitals in Australia

BACKGROUND

There is a paucity of literature in Australia on patient-focused tracheostomy outcomes and process outcomes. Exploration of processes of care enables teams to identify and address existing barriers that may prevent earlier therapeutic interventions that could improve patient outcomes following critical care survival.

OBJECTIVES

The objectives of this study were to examine and provide baseline data and associations between tracheostomy clinical practices and patient outcomes across three large metropolitan hospitals.

METHODS

We performed a retrospective multisite observational study in three tertiary metropolitan Australian health services who are members of the Global Tracheostomy Collaborative. Deidentified data were entered into the Global Tracheostomy Collaborative database from Jan 2016 to Dec 2019. Descriptive statistics were used for the reported outcomes of length of stay, mortality, tracheostomy-related adverse events and complications, tracheostomy insertion, airway, mechanical ventilation, communication, swallowing, nutrition, length of cannulation, and decannulation. Pearson's correlation coefficient and one-way analyses of variance were performed to examine associations between variables.

RESULTS

The total cohort was 380 patients. The in-hospital mortality of the study cohort was 13%. Overall median hospital length of stay was 46 days (interquartile range: 31-74). Length of cannulation was shorter in patients who did not experience any tracheostomy-related adverse events (p= 0.036) and who utilised nonverbal communication methods (p = 0.041). Few patients (8%) utilised verbal communication methods while mechanically ventilated, compared with 80% who utilised a one-way speaking valve while off the ventilator. Oral intake was commenced in 20% of patients prior to decannulation. Patient nutritional intake varied prior to and at the time of decannulation. Decannulation occurred in 83% of patients.

CONCLUSIONS

This study provides baseline data for tracheostomy outcomes across three large metropolitan Australian hospitals. Most outcomes were comparable with previous international and local studies. Future research is warranted to explore the impact of earlier nonverbal communication and interventions targeting the reduction in tracheostomy-related adverse events.

Symptom Assessment for Mechanically Ventilated Patients: Principles and Priorities: An Official American Thoracic Society Workshop Report

Mechanically ventilated patients experience many adverse symptoms, such as anxiety, thirst, and dyspnea. However, these common symptoms are not included in practice guideline recommendations for routine assessment of mechanically ventilated patients. An American Thoracic Society-sponsored workshop with researchers and clinicians with expertise in critical care and symptom management was convened for a discussion of symptom assessment in mechanically ventilated patients. Members included nurses, physicians, a respiratory therapist, a speech-language pathologist, a critical care pharmacist, and a former intensive care unit patient. This report summarizes existing evidence and consensus among workshop participants regarding 1) symptoms that should be considered for routine assessment of adult patients receiving mechanical ventilation; 2) key symptom assessment principles; 3) strategies that support symptom assessment in nonvocal patients; and 4) areas for future clinical practice development and research. Systematic patient-centered assessment of multiple symptoms has great potential to minimize patient distress and improve the patient experience. A culture shift is necessary to promote ongoing holistic symptom assessment with valid and reliable instruments. This report represents our workgroup consensus on symptom assessment for mechanically ventilated patients. Future work should address how holistic, patient-centered symptom assessment can be embedded into clinical practice.

Defining effective communication for critically ill patients with an artificial airway: An international multi-professional consensus

OBJECTIVES

To define effective communication and identify its key elements specific to critically ill patients with an artificial airway.

DESIGN

A modified Consensus Development Panel methodology.

SETTING

International video-conferences.

MAIN OUTCOME MEASURES

Definition of effective communication and it's key elements.

RESULTS

Eight experts across four international regions and three professions agreed to form the Consensus Development Panel together with a Chair and one person with lived experience who reviewed the outputs prior to finalisation. "Communication for critically ill adult patients with an artificial airway (endotracheal or tracheostomy tube) is defined as the degree in which a patient can initiate, impart, receive, and understand information, and can range from an ineffective to effective exchange of basic to complex information between the patient and the communication partner(s). Effective communication encompasses seven key elements including: comprehension, quantity, rate, effort, duration, independence, and satisfaction. In critically ill adults, communication is impacted by factors including medical, physical and cognitive status, delirium, fatigue, emotional status, the communication partner and the nature of the ICU environment (e.g., staff wearing personal protective equipment, noisy equipment, bright lights)." The panel agreed that communication occurs on a continuum from ineffective to effective for basic and complex communication.

CONCLUSION

We developed a definition and list of key elements which constitute effective communication for critically ill patients with an artificial airway. These can be used as the basis of standard terminology to support future research on the development of communication-related outcome measurement tools in this population.

IMPLICATIONS FOR CLINICAL PRACTICE

This study provides international multi-professional consensus terminology and a definition of effective communication which can be used in clinical practice. This standard definition and key elements of effective communication can be included in our clinical impressions of patient communication, and be used in discussion with the patient themselves, their families and the multi-professional team, to guide care, goal development and intervention.

Outcome measurement tools for communication, voice and speech intelligibility in the ICU and their clinimetric properties: A systematic review

Purpose

To identify outcome measurement tools used to evaluate communication, voice and speech intelligibility in the mechanically ventilated ICU population. Secondly, to evaluate, synthesise and compare the clinimetric properties of the tools identified.

Materials and methods

A systematic review of articles was undertaken via electronic databases in two parts. Eligibility criteria for selection: part one - quantitative or mixed methods studies which assessed communication, voice or speech intelligibility; part two - studies which evaluated a clinimetric property for one of the tools identified in part one. Two independent reviewers assessed articles for inclusion and used the consensus-based standards for health status measurement instruments (COSMIN) risk of bias checklist.

Results

The part one search yielded five included studies comprised of eight outcome measurement tools. The part two search yielded 22 included studies comprised of nine tools. Few studies had adequate reliability and measurement error properties. No studies established responsiveness. A notable proportion of studies utilised tools that have no clinimetric properties.

Conclusions

There is a relatively small number of studies which have established clinimetric properties for outcome measurement tools that evaluate communication, voice and/or speech intelligibility, and a fewer number which have done so in the mechanically ventilated ICU population.

An Update on Cardiorespiratory Physiotherapy during Mechanical Ventilation

Physiotherapists are integral members of the multidisciplinary team managing critically ill adult patients. However, the scope and role of physiotherapists vary widely internationally, with physiotherapists in some countries moving away from providing early and proactive respiratory care in the intensive care unit (ICU) and focusing more on early mobilization and rehabilitation. This article provides an update of cardiorespiratory physiotherapy for patients receiving mechanical ventilation in ICU. Common and some more novel assessment tools and treatment options are described, along with the mechanisms of action of the treatment options and the evidence and physiology underpinning them. The aim is not only to summarize the current state of cardiorespiratory physiotherapy but also to provide information that will also hopefully help support clinicians to deliver personalized and optimal patient care, based on the patient's unique needs and guided by accurate interpretation of assessment findings and the current evidence. Cardiorespiratory physiotherapy plays an essential role in optimizing secretion clearance, gas exchange, lung recruitment, and aiding with weaning from mechanical ventilation in ICU. The physiotherapists' skill set and scope is likely to be further optimized and utilized in the future as the evidence base continues to grow and they get more and more integrated into the ICU multidisciplinary team, leading to improved short- and long-term patient outcomes.

iPad-based Apps to Facilitate Communication in Critically Ill Patients with Impaired Ability to Communicate: A Preclinical Analysis

Background

Inability to communicate is very distressing for patients in the intensive care unit (ICU). Most communication exchanges in ICU are initiated by healthcare workers (HCWs). Touch screen apps may enable patients to initiate communication and improve their interactions.

Objectives

This study aimed to evaluate the pertinent features of iPad-based apps designed for communication in ICU.

Methods

Apple “App Store” and Google “Play Store” were searched for keywords “communication” and “intensive care.” Related app suggestions were screened. Two independent assessors evaluated iPad-based apps that were deemed useful. The assessors resolved the discrepancies by re-evaluating the apps and reaching a consensus.

Results

Nine apps met the inclusion criteria. Of these six apps were free. There were seven apps specific to intensive care. Most apps had preloaded phrases for the patient to request to see someone (e.g., family), personal hygiene (e.g., bowel care), seek help with symptoms (e.g., pain), or a comfort item (e.g., blanket). CALD Assist, Patient Communicator, VidaTalk, and YoDoc were available in more than eight languages. VidaTalk and YoDoc allowed the user to write. Four apps were deemed not suitable for routine ICU use, while the remaining five had several attractive features.

Conclusion

Several high-quality apps are available to assist with patient-initiated communication exchange in ICU. This study provides a guide for readers to choose the app most suited to their needs. In the opinion of the authors, YoDoc is the most suitable app for routine use in ICU. Among free apps, CommuniCare appears to be the most user-friendly.

How to cite this article

Dind AJ, Starr JS, Arora S. iPad-based Apps to Facilitate Communication in Critically Ill Patients with Impaired Ability to Communicate: A Preclinical Analysis. Indian J Crit Care Med 2021;25(11):1232–1240.

The relationship between person-centred care and the intensive care unit experience of critically ill patients: A multicentre cross-sectional survey

BACKGROUND

Person-centred care has the potential to improve the patient experience in the intensive care unit (ICU). However, the relationship between person-centred care perceived by critically ill patients and their ICU experience has yet to be determined.

OBJECTIVES

The aim of this study was to investigate the relationship between person-centred care and the ICU experience of critically ill patients.

METHODS

This study was a multicentre, cross-sectional survey involving 19 ICUs of four university hospitals in Busan, Korea. The survey was conducted from June 2019 to July 2020, and 787 patients who had been admitted to the ICU for more than 24 hours participated. We measured person-centred care using the Person-Centered Critical Care Nursing perceived by Patient Questionnaire. Participants' ICU experience was measured by the Korean version of the Intensive Care Experience Questionnaire that consists of four subscales. We analysed the relationship between person-centred care and each area of the ICU experience using multivariate linear regression.

RESULTS

Person-centred care was associated with 'awareness of surroundings' (β = 0.29, p < .001), 'frightening experiences' (β = -0.31, p < .001), and 'satisfaction with care' (β = 0.54, p < .001). However, there was no significant association between person-centred care and 'recall of experience'.

CONCLUSIONS

We observed that person-centred care was positively related to most of the ICU experiences of critically ill patients except for recall of experience. Further studies on developing person-centred nursing interventions are needed.

A multicomponent intervention to optimise nurse-patient communication in the intensive care unit: A mixed-methods acceptability and feasibility study

BACKGROUND

Mechanically ventilated patients in intensive care units may experience communication challenges owing to intubation, which affects nurse-patient communication. Several strategies may optimise communication, but only one previous study has tested a multicomponent intervention. Implementing such an intervention can be challenging because communication strategies may be set aside by lifesaving care tasks and procedures. In a previous study, we designed a communication intervention based on pre-existing clinical methods and evidence-based approaches. The present study evaluated the intervention to determine if it was necessary to adjust its components and the implementation strategy.

OBJECTIVES

The objective of this study was to evaluate the feasibility and assess nurses' acceptability of a patient-centred, multicomponent communication intervention prototype in an intensive care unit.

METHODS

The overall frame was the Medical Research Council's framework for developing complex interventions. Indicators of feasibility and acceptability were used for the evaluation. A mixed-methods design was applied including a survey with open-ended text boxes and qualitative observations as data sources. Quantitative data were analysed descriptively, and qualitative data were explored using content analysis. Data were compiled and displayed in a side-by-side comparison. The data were collected between September 2020 and March 2021. Nurses from four intensive care units at a university hospital in Denmark participated in the study. All nurses who were on active duty during the implementation of the intervention were enrolled for the survey and participant observations.

RESULTS

Overall, the results provided insight into the feasibility based on fidelity and context as well as nurses' acceptability based on adherence, appropriateness, convenience, and effectiveness. Qualitative and quantitative results yielded partially contrasting findings but highlighted how the intervention may be optimised to enhance fit with clinical practice and overcome implementation challenges.

CONCLUSION

The intervention was feasible and acceptable. However, implementation needs to be repeated to allow nurses to fully understand and use the intervention.

Evidence-Based Communication with Critically Ill Older Adults

Communication is a critical component of patient-centered care. Critically ill, mechanically ventilated patients are unable to speak and this condition is frightening, frustrating, and stressful. Impaired communication in the intensive care unit (ICU) contributes to poor symptom identification and restricts effective patient engagement. Older adults are at higher risk for communication impairments in the ICU because of pre-illness communication disorders and cognitive dysfunction that often accompanies or precedes critical illness. Assessing communication disorders and developing patient-centered strategies to enhance communication can lessen communication difficulty and increase patient satisfaction.

Approach to the basic needs in patients on invasive ventilation using eye-tracking devices for non-verbal communication

PURPOSE

To analyze the feasibility of eye-tracking (ET) devices as a communicative approach to the basic needs (BN) of intensive care unit (ICU) and invasively ventilated nonverbal patients.

METHODS

Prospective, monocentric, and observational study including all patients without delirium, with an endotracheal tube or tracheostomy tube, with a history of invasive ventilation for more than 48 h, and inadequate nonverbal communication skills. The investigation was performed with commercially available ET devices (Tobii Dynavox I-15+) to express BN of ICU patients following a standardized 30-item yes-or-no questionnaire.

RESULTS

A total of 64 patients with a mean age of 58.6 years were included. The main diagnoses for ICU admission were major trauma (43.6%), sepsis (21.8%), and acute abdomen (15.6%). Pain during repositioning (69%), thirst (69%), sleep disorders (66%), fatigue (64%), and anxiety regarding the lifelong need for assistance (64%) were the main problems reported by the patients. However, most of the patients described expectations of health improvement (78%), good family support (66%), and an improvement in quality of life due to the use of ET devices (67%).

CONCLUSION

The use of ET in selected ICU patients with impaired communication is feasible, allowing them to express their BN. Apart from knowing the patients' individual BN, the results of our BN questionnaire may provide guidance for improvement measures in the care of patients in the ICU who are unable to speak. We believe that ET is useful for inquiring about and expressing BN and, therefore, may be capable of improving patient-medical team interactions and patient satisfaction.

Interventions to enable communication for adult patients requiring an artificial airway with or without mechanical ventilator support

BACKGROUND

Inability to communicate in a manner that can be understood causes extreme distress for people requiring an artificial airway and has implications for care quality and patient safety. Options for aided communication include non-vocal, speech-generating, and voice-enabling aids.

OBJECTIVES

To assess effectiveness of communication aids for people requiring an artificial airway (endotracheal or tracheostomy tube), defined as the proportion of people able to: use a non-vocal communication aid to communicate at least one symptom, need, or preference; or use a voice-enabling communication aid to phonate to produce at least one intelligible word. To assess time to communication/phonation; perceptions of communication; communication quality/success; quality of life; psychological distress; length of stay and costs; and adverse events.

SEARCH METHODS

We searched the Cochrane Library (Wiley version), MEDLINE (OvidSP), Embase (OvidSP), three other databases, and grey literature from inception to 30 July 2020.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, cluster-RCTs, controlled non-randomised parallel group, and before-after studies evaluating communication aids used in adults with an artificial airway.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. Two review authors independently performed data extraction and assessment of risk of bias.

MAIN RESULTS

We included 11 studies (1931 participants) conducted in intensive care units (ICUs). Eight evaluated non-vocal communication aids and three voice-enabling aids. Usual care was the comparator for all. For six studies, this comprised no aid; usual care in the remaining five studies comprised use of various communication aids. Overall, our confidence in results regarding effectiveness of communication interventions was very low due to imprecision, measurement heterogeneity, inconsistency in results, and most studies at high or unclear risk of bias across multiple domains. No non-vocal aid studies reported our primary outcome. We are uncertain of the effects of early use of a voice-enabling aid compared to routine use on ability to phonate at least one intelligible word (risk ratio (RR) 3.03, 95% confidence interval (CI) 0.18 to 50.08; 2 studies; very low-certainty evidence). Compared to usual care without aids, we are uncertain about effects of a non-vocal aid (communication board) on patient satisfaction (standardised mean difference (SMD) 2.92, 95% CI 1.52 to 4.33; 4 studies; very low-certainty evidence). No studies of non-vocal aids reported quality of life. Low-certainty evidence from two studies suggests early use of a voice-enabling aid may have no effect on quality of life (MD 2.27, 95% CI -7.21 to 11.75). Conceptual differences in measures of psychological distress precluded data pooling; however, intervention arm participants reported less distress suggesting there might be benefit, but our certainty in the evidence is very low. Low-certainty evidence suggest voice-enabling aids have little or no effect on ICU length of stay; we were unable to determine effects of non-vocal aids. Three studies reported different adverse events (physical restraint use, bleeding following tracheostomy, and respiratory parameters indicating respiratory decompensation). Adverse event rates were similar between arms in all three studies. However, uncertainty remains as to any harm associated with communication aids.

AUTHORS' CONCLUSIONS

Due to a lack of high-quality studies, imprecision, inconsistency of results, and measurement heterogeneity,  the evidence provides insufficient information to guide practice as to which communication aid is more appropriate and when to use them. Understanding effectiveness of communication aids would benefit from development of a core outcome measurement set.

Computer-Based Communication Tool Provides Effective Communication for Non-speaking Patients: A Quasi-experimental Study

Even though they are conscious, patients who are unable to speak while connected to a mechanical ventilator have serious difficulties in communicating with healthcare staff. This research aimed to determine the effectiveness for patients of a computer-based communication tool (CBCT) and to compare these results with patients using a routine method. This quasi-experimental study was conducted with 90 intubated patients. It was found that 20.0% of the patients using CBCT stated that they had difficulties in communicating, while this rate was 82.2% among patients not using CBCT. Compared with participants in the control group, experimental group patients reported a lower median score for the anxiety levels (23.0 [20.0-39.0], 29.0 [20.0-57.00], p < .001) and higher mean comfort levels (130.2 ± 9.0, 109.6 ± 13.3, p < .001). Positive impacts of the CBCT are its suitability for patients who are dependent upon ventilation for different reasons and their improved ability to communicate effectively.

Evidence for Above Cuff Vocalization in Patients With a Tracheostomy: A Systematic Review

OBJECTIVES/HYPOTHESIS

To determine how above cuff vocalization (ACV) is implemented in clinical practice, to identify what evidence exists on the effectiveness and safety of ACV, and to evaluate the acceptability of ACV.

STUDY DESIGN

Systematic review.

METHODS

A literature search was conducted in eight databases (MEDLINE, Embase, AMED, CINAHL, Cochrane Library, PsycINFO, Scopus, and Web of Science) in May 2019 and updated in June 2020. Two reviewers independently screened, selected, and extracted data. Study quality was appraised using the Joanna Briggs Institute Critical Appraisal Tools and a narrative synthesis was conducted. Systematic review registration number: CRD42019133942.

RESULTS

The searches identified 1327 records. The 13 eligible studies included four case studies, three case series, four observational studies without a control group, one quasi-experimental study, and one randomized controlled trial. Study quality was low, with most studies having high risk of bias. There was a high level of heterogeneity in study design and outcome measures used. Detailed information on ACV application and dose-delivered was lacking in 12 studies. Positive effects were reported for communication (n = 7), swallowing (n = 4), cough response (n = 2), and quality-of-life (n = 2), but with inconsistent use of objective outcome measures. There is limited quantitative or qualitative evidence for acceptability. Adverse events and complications were reported in nine studies, and four highlighted the importance of involving an experienced speech and language therapist.

CONCLUSIONS

There is limited evidence for the acceptability, effectiveness, safety, or optimal implementation of ACV. The evidence is insufficient to provide recommendations regarding optimal intervention delivery. Future research should ensure detailed recording of ACV delivery and utilize a core outcome set. Laryngoscope, 2021.

Standard versus Accelerated Speaking Valve Placement after Percutaneous Tracheostomy: A Randomized-Controlled Feasibility Study

RATIONALE

Feasibility of a large, multi-center, randomized controlled trial (RCT) comparing the risks and benefits of early use speaking valve following tracheostomy is not clear.

OBJECTIVE

To investigate the feasibility of accelerated (≤ 24 hours) versus standard (≥ 48 hours) one-way speaking valve ("speaking valve") placement after percutaneous tracheostomy.

METHOD

Twenty awake patients (Glasgow Coma Scale score >9) were randomized to accelerated or standard timing of speaking valve placement. Outcomes included patient identification and recruitment, adherence to protocol-defined time windows for valve placement, experimental separation in time to first speaking valve placement between groups, effectiveness of speech and swallowing (sentence intelligibility test [SIT] score, patient-reported quality of life [QOL]), and clinical outcomes (safety events, speaking valve tolerance, decannulation, length of stay, mortality).

RESULTS

Of 161 patients undergoing percutaneous tracheostomy, 20 of 36 meeting eligibility criteria were randomized. The median time to speaking valve placement was 22 (IQR: 21, 23) hours in the accelerated arm versus 45.5 (IQR: 43, 50) hours for the standard arm. No aspiration, hypoxemia, or other safety events occurred in either arm as a result of the speaking valve. SIT scores were not different between arms but correlated with QOL. After 3 sessions, patients in the accelerated arm tolerated longer speaking valve trials than the standard arm [Median (IQR): 65 (45 - 720) vs. 15 (3-20) minutes]. Seven patients in the accelerated arm were decannulated before hospital discharge versus one patient in the standard arm.

CONCLUSIONS

Speaking valve placement within 24 hours of percutaneous tracheostomy is feasible. A multicenter, randomized, control trial should be conducted to evaluate the safety of this strategy and compare important clinical outcomes, including time to speech and swallow recovery following tracheostomy. Clinical trial registered with ClinicalTrials.gov (NCT03008174).

A atuação do terapeuta ocupacional em Unidade de Terapia Intensiva: uma revisão sistemática

Resumo Introdução A participação do terapeuta ocupacional (TO) em Unidades de Terapia Intensiva (UTI) ainda é discreta no Brasil, talvez, por isso, haja pouca discussão das intervenções e inserção do profissional nessa área. Objetivo Sintetizar as atuações do TO para restabelecimento da função em pacientes adultos internados na UTI mais frequentemente descritas na literatura especializada. Método Revisão Sistemática baseada na recomendação PRISMA. A busca dos estudos foi realizada nas plataformas Cochrane, PubMed, OTSeek e PEDro, utilizando os termos de busca “Occupational Therapy”, no título ou resumo, (AND) “Intensive Care Unit” (OR) “Critical Illness” (OR) “Critical Care”, em outras partes do texto. Foram incluídos textos em língua inglesa e publicados nos últimos 20 anos. Excluiu-se textos que abordavam UTI pediátrica/neonatal, doenças psiquiátricas e artigos de revisão. Dois pesquisadores independentes selecionaram os artigos e a concordância foi submetida à análise Kappa. O nível de evidência e a qualidade metodológica dos estudos incluídos foram avaliados pela Escala PEDro e pela Ferramenta de Colaboração Cochrane, respectivamente. Resultados As principais intervenções foram relativas ao treino de Atividades de Vida Diária (AVDs) e tarefas relacionadas às Atividades Instrumentais de Vida Diária (AIVDs). Essas atribuições privativas da profissão ocorreram isoladamente ou com fisioterapeutas. As sessões, excluídos os critérios de contraindicação, aconteceram precocemente (24-48h). Conclusão Os achados evidenciam intervenções de mobilização precoce, seguidas por práticas de treino de AVDs/ AIVDs. Ademais, é notado que a atuação do terapeuta ocupacional na UTI está em elaboração. Estudos sobre outros efeitos da internação prolongada na UTI devem ser conduzidos. Registro PROSPERO: CRD42020214615.

Above cuff vocalisation (ACV): A scoping review

Introduction

Patients in intensive care frequently suffer from not being able to communicate verbally. The aim of this scoping review was to study the safety and effectiveness of the above cuff vocalisation (ACV) on speech and quality of life (QOL) in patients dependent on a cuffed tracheostomy.

Methods

A scoping review was conducted. The databases Ovid Medline, Cochrane Library, and Embase were systematically searched in May 2020. We included clinical studies with patients exposed to ACV where speech, QOL or safety issues were assessed.

Results

Overall, 17 studies were included, of which 15 were observational and 2 were randomised controlled trials. Totally, 231 patients were included. ACV enabled most of the included patients (115/131; 88%) to speak with an audible voice or whisper (moderate quality of evidence). Voice related QOL (V‐RQOL) and QOL in mechanically ventilated patients (QOL‐MV) improved from pre‐ to post‐ ACV compared to a control group not tolerating a one‐way speaking valve (P = .01 and P = .04, respectively) (very low quality of evidence). Several minor complications or problems were reported in 20/75 (27%) cases in addition to two serious adverse events: subcutaneous emphysema in one patient where the tracheostomy was dislodged and a distended trachea in another due to the misconnection of continuous gas to the cuff (low/ very low quality of evidence).

Conclusion

ACV facilitated communication in patients dependent on a cuffed tracheostomy and attempting to communicate. Quality of evidence in improved V‐RQOL and QOL‐MV was very low. Several minor complications and two serious adverse events were reported.

A systematic review on voiceless patients' willingness to adopt high-technology augmentative and alternative communication in intensive care units

OBJECTIVE

To systematically evaluate the acceptability of high-technology augmentative and alternative communication (high-tech AAC) among ICU patients who are voiceless guided by the technology acceptance model (TAM).

METHODS

We searched the Cochrane Library, EMBASE, PubMed, CINAHL, PsycINFO, Web of Science, SinoMed, China National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database and Wanfang Database from database inception to September 2019. Studies that examined conscious nonverbal ICU patients with high-tech AAC intervention were included. Two reviewers independently collected and evaluated all the studies. The methodological quality was assessed by using the Joanna Briggs Institute critical appraisal tool.

RESULTS

Eighteen studies with a total of 914 patients met the inclusion criteria, and the quality of the studies varied from low to moderate. Based on the TAM, ICU voiceless patients perceived that high-tech AAC was useful, was easy to use, decreased communication difficulties, reduced negative emotions, and improved symptom identification and management. Patients maintained a positive attitude and were willing to continue to use high-tech AAC.

CONCLUSIONS

Although the existing evidence is limited, voiceless patients regard high-tech AAC devices as a useful, reliable, and acceptable alternative communication choice in the ICU. Multicenter, large-sample, and high-quality studies are highly recommended in the future.

Evidence-Based Communication with Critically Ill Older Adults

Communication is a critical component of patient-centered care. Critically ill, mechanically ventilated patients are unable to speak and this condition is frightening, frustrating, and stressful. Impaired communication in the intensive care unit (ICU) contributes to poor symptom identification and restricts effective patient engagement. Older adults are at higher risk for communication impairments in the ICU because of pre-illness communication disorders and cognitive dysfunction that often accompanies or precedes critical illness. Assessing communication disorders and developing patient-centered strategies to enhance communication can lessen communication difficulty and increase patient satisfaction.

Multidisciplinary Safety Recommendations After Tracheostomy During COVID-19 Pandemic: State of the Art Review

OBJECTIVE

In the chronic phase of the COVID-19 pandemic, questions have arisen regarding the care of patients with a tracheostomy and downstream management. This review addresses gaps in the literature regarding posttracheostomy care, emphasizing safety of multidisciplinary teams, coordinating complex care needs, and identifying and managing late complications of prolonged intubation and tracheostomy.

DATA SOURCES

PubMed, Cochrane Library, Scopus, Google Scholar, institutional guidance documents.

REVIEW METHODS

Literature through June 2020 on the care of patients with a tracheostomy was reviewed, including consensus statements, clinical practice guidelines, institutional guidance, and scientific literature on COVID-19 and SARS-CoV-2 virology and immunology. Where data were lacking, expert opinions were aggregated and adjudicated to arrive at consensus recommendations.

CONCLUSIONS

Best practices in caring for patients after a tracheostomy during the COVID-19 pandemic are multifaceted, encompassing precautions during aerosol-generating procedures; minimizing exposure risks to health care workers, caregivers, and patients; ensuring safe, timely tracheostomy care; and identifying and managing laryngotracheal injury, such as vocal fold injury, posterior glottic stenosis, and subglottic stenosis that may affect speech, swallowing, and airway protection. We present recommended approaches to tracheostomy care, outlining modifications to conventional algorithms, raising vigilance for heightened risks of bleeding or other complications, and offering recommendations for personal protective equipment, equipment, care protocols, and personnel.

IMPLICATIONS FOR PRACTICE

Treatment of patients with a tracheostomy in the COVID-19 pandemic requires foresight and may rival procedural considerations in tracheostomy in their complexity. By considering patient-specific factors, mitigating transmission risks, optimizing the clinical environment, and detecting late manifestations of severe COVID-19, clinicians can ensure due vigilance and quality care.

Nurses' communication with mechanically ventilated patients in the intensive care unit: Umbrella review

AIM

To conduct a review summarizing evidence concerning communication with mechanically ventilated patients in the intensive care unit (ICU).

BACKGROUND

ICU patients undergoing mechanical ventilation are unable to communicate verbally, causing many negative emotions. Due to changes in sedation practice, a growing number of patients are conscious and experience communication difficulties.

DESIGN

The umbrella review method guided by the Joanna Briggs Institute was applied.

DATA SOURCES

A systematic search was done in the Cochrane Library, the Joanna Briggs Institute database, Cinahl, Pubmed, PsycINFO and Scopus between January -April 2019. Search terms were 'nurse-patient communication', 'mechanical ventilation', 'intensive care', and 'reviews as publication type'. Literature from 2009-2019 was included.

REVIEW METHODS

Following recommendations by the Joanna Briggs Institute, a quality appraisal, data extraction, and synthesis were done.

RESULTS

Seven research syntheses were included. There were two main themes and six subthemes: (1) Characterization of the nurse-patient communication: (a) Patients' communication; (b) Nurses' communication; (2) Nursing interventions that facilitate communication: (a) Communication assessment and documentation; (b) Communication methods and approaches; (c) Education and training of nurses; and (d) Augmentative and alternative communication.

CONCLUSION

Nurse-patient communication was characterized by an unequal power relationship with a common experience - frustration. Four key interventions were identified and an integration of these may be key to designing and implementing future ICU communication packages.

IMPACT

Nurse-patient communication is characterized by an unequal power relationship with one joint experience - frustration. Four key interventions should be integrated when designing and implementing communication packages in the ICU. Findings are transferable to ICU practices where patients are conscious and experience communication difficulties.

Speech-Language Pathology Guidance for Tracheostomy During the COVID-19 Pandemic: An International Multidisciplinary Perspective

Purpose As the COVID-19 pandemic has unfolded, there has been growing recognition of risks to frontline health care workers. When caring for patients with tracheostomy, speech-language pathologists have significant exposure to mucosal surfaces, secretions, and aerosols that may harbor the SARS-CoV-2 virus. This tutorial provides guidance on practices for safely performing patient evaluation and procedures, thereby reducing risk of infection. Method Data were collated through review of literature, guidelines, and consensus statements relating to COVID-19 and similar high-consequent infections, with a focus on mitigating risk of transmission to health care workers. Particular emphasis was placed on speech-language pathologists, nurses, and other allied health professionals. A multinational interdisciplinary team then analyzed findings, arriving at recommendations through consensus via electronic communications and video conference. Results Reports of transmission of infection to health care workers in the current COVID-19 pandemic and previous outbreaks substantiate the need for safe practices. Many procedures routinely performed by speech-language pathologists have a significant risk of infection due to aerosol generation. COVID-19 testing can inform level of protective equipment, and meticulous hygiene can stem spread of nosocomial infection. Modifications to standard clinical practice in tracheostomy are often required. Personal protective equipment, including either powered air-purifying respirator or N95 mask, gloves, goggles, and gown, are needed when performing aerosol-generating procedures in patients with known or suspected COVID-19 infection. Conclusions Speech-language pathologists are often called on to assist in the care of patients with tracheostomy and known or suspected COVID-19 infection. Appropriate care of these patients is predicated on maintaining the health and safety of the health care team. Careful adherence to best practices can significantly reduce risk of infectious transmission.