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					    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
 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
• 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.
  Part I

   Descriptive reports of the
mechanical ventilation experience
           in the ICU
• Patients experience:
  • FEAR

• As a result of the inability to speak
Nurse-Patient communication in ICU:
 Brief (< 5 min), task-oriented, commands &
  reassurances during physical care.
 Patients typically communicate
with nods, gestures, and mouthing
 ICU interactions do NOT usually involve
communication of the patient’s ideas,
patient’s initiation of messages or elaboration.
 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.
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)
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)
         A need exists for:
• Specific data on communication
  interventions for nonspeaking, intensive
  care unit patients
• Analysis of high tech versus low tech
• Perceptual, qualitative, and quantitative
• Comparisons between different ICU
• Usage data as well as interactional data
General Design of 2
 Feasibility Studies
Explore the feasibility of electronic voice
    output communication aids (VOCAs)
    for use with nonvocal patients
(1) in a medical ICU and
(2) following head-neck cancer surgery.
Research Questions
What are the …
   Patient characteristics (illness
    severity, neuromotor ability)
   Usage patterns (message categories,
    frequency, assistance required)
   Communication quality (ease,
   Barriers to communication
…when VOCAs are used by
 hospitalized adults?
Complementary Design

       QUAL + quan
      No hypotheses
 Purposive-theoretical sampling
       Small samples
                       Morgan, 1998
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
       Education & Set-Up
Nurse Inservice (15 min)
Patient Instruction (20 min) +
Message Inventories
  • What does he/she want to say?
  • To whom?
  • How?                 *Costello, 2000
                Data Collection
  Pre-test Ease of Communication Scale2
  APACHE, Motor Screen1
  Observations (20min)
  Chart Review
  Post-test Ease of Communication Scale2
  Exit Interviews

1.   P. Dowden et al. (1986)   2   L.. Menzel (1998).
       Part II
   Pilot Research:
Head and Neck Surgical
Dr. Richard Hurtig, University of Iowa
Stephanie Williams, SLP, Dynavox Systems, Inc
  AACN/ Sigma Theta Tau
  ONS Foundation/ OrthoBiotech
Equipment donations:
  DynaVox Systems, Inc.
  WordsPlus, Inc.

DynaMyte    Electronic VOCAs

                    Message   TM

Examples of

1                   SICK MEDICINE Pain shot
                                                              NAUSEA    Say
    NOT OK I’m OK                                    PAIN
2    HOT                                      SAD    HAPPY ANGRY Space

3                   BATH GLASSES
                                     CARE SUCTION    DRINK    BEDPAN
      TV    MUSIC

                             LOVE                    WHY?
            DOCTOR FAMILY    YOU    HOME      HEAR   WHERE?   TIME


     CAT    MOUTH     DOG
Basic Messages
   Pain
   Shortness of Breath
   Suction
   Help!
   Hot/Cold
   Home/Family
   Anxiety/Worry

swivel arm
Qualitative Data Analysis
Fieldnotes and interviews coded for:
  1.    method
  2.    content
  3.    barriers
  4.    facilitators
Quantitative Data Analysis
Descriptive statistics (dispersion)
Pattern recognition
Nonparametric within case
 comparison (EOC)
   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
Head & Neck Sample

     7 men, 3 women
     all Caucasian
     5 MessageMate
     5 DynaMyte
 Observation & Interview

 Observations:                = 66
  Communication Events         = 50 (75.8%)

 Formal Interviews:           = 9
               Patient   = 8
               Nurse     = 1
     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
 Brachytherapy   2

 Laryngectomy    8
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)
  Neuromotor Characteristics

+ Motor Screen Tasks      = 10

+ Write legibly    = 10

+ Narcotics/sedation      = 35/50 (70%)
          Usage Patterns
• VOCAs were used by some of the post
  surgical patients
     - some required extensive assistance,
     whereas others required limited or no
• Other modalities were used as well
    - Gesture
    - Mouthing Words
    - Head Nods
            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.
   Novel Scenarios in which
     VOCAS were used
1. Cardiology evaluation

2. Telephone usage
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
      Message Content

   Comfort needs (pain, thirst, suction)
   Questions about home & family
   “I love you” 
   Questions about tests and
   Phone conversations
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
Case Study
• 46 year old Caucasian male
• S/P Total laryngectomy & tooth
• No prior history of intubation and
  mechanical ventilation
• No significant past medical history
•   High school graduate
•   Previous personal computer use
•   Vision corrected with eyeglasses
•   Right hand dominance
• Motor screening tasks
• APACHE score = 29
• Glasgow Coma Scale (GCS) = 15
• 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
            Device Set Up
• Device options
   Message Mate- simple, smaller message
  DynaMyte- larger capacity, multi-level
    message display

• At bedside
• Duration ~1.5 hours
• Initial method of communication
   • Writing/Gestures
            Tim’s Requests
• Voice selection

• Message deletions
  • “Yes/No”
  • “What time is it?”

• Message Additions
  • “Hello” & “Good-bye”
          Tim’s Requests
• Icon/Message change
   • Performed at bedside
   • Requested by patient and/or family
   • During entire enrollment period

• Affect change
        Observation of
     Communication Events
• 7 OCE’s from 5 study days
• Narcotic analgesia
   • 5/7 OCE’s

• Additional non-AAC methods
  • Head Nods
  • Hand Gestures
            Tim’s AAC Use
• Most utilized mode
  • Keyboard feature
     Utilized bilateral hands predominantly
      index fingers and thumb

• 6 available “pop-up” icons with additional
   • Effective navigation
   General Interactions with
          AAC Use
• Convey feelings to nurse
  • Pain
  • Anxiety
• Establishing need for suctioning
• Requesting assistance in bathing
• Communication with RN’s, MD’s, family
 Aspects of AAC Use

   Positive           Negative

  Ownership        Time Consuming

Sense of Control    Unfamiliarity

Connection with
                    Use of space
• Tim
   • “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.”
       Practical Challenges
• Patient lost access to the device when he
  transferred off of the Head and Neck Unit (to
• Expensive
• Nursing, Physician, Clinician unfamiliarity
• Battery back up
• Infection control issue -- how to keep the
  device sterile
• Discharge to home without device?
             Tim Taught Us
• Communication method needs to be
  customized for each patient
• Options for changes/deletions of various
  messages at all times
• Once a method is established, it is difficult to
  change or add another method
   Results of this exploratory
   study will be submitted for

• Stay tuned…you will be able to access
  more specific data after the manuscript
  has been accepted to a peer-reviewed
      Part III

Pilot Study #2 -- Medical
Intensive Care Unit
   Exploring the Feasiblity of
  VOCAs with Nonspeaking ICU

M.B. Happ, PhD
T. K. Roesch, BSN
   MICU Sample

 15 patients identified
 11 participated (73%)
 7 men, 4 women
 10 Caucasian
 Observation & Interview

 Observations:             = 49
  Communication Events      = 41 (83.7%)

 Formal Interviews:         = 14
               Patient = 8
               Family    = 3
               Clinician = 3
 Characteristics (n=11)
 Ages:             20-72 yrs (45.5+16)

 Education:         0-16+ yrs (13+1.9)*

 Computer       Use: 6

  *MR patient excluded from mean
   Intubation:
       Tracheostomy:   4
       Oral ET tube:   7

   Primary Medical Dx:
    Pneumonia/ARDS/Sepsis       7
    Lung CA                         1
    COPD                        1
    Subglottic Stenosis         1
    SCI                     1
Characteristics (cont).
 Days w/   device: 1-14 (5.7+ 4.6)

 Ventilator   Days: 1-44 (15.5+12.2)

 APACHE III:        10-54
Neuromotor Characteristics
     (n=11 Study Patients)

   + Motor Screen Tasks = 8
     - Blind, quadriplegia
     - Quadriplegia
     - Morbid Obesity

   + Write legibly = 3
 Neuromotor Characteristics
        (n=49 observations)

 Narcotic   analgesia   = 13 (26.5%)

 Anxiolytics/sedation       = 22
           Usage Patterns
• Ventilated patients in the MICU used VOCA
  systems in over 1/4 of the observed
  communication events
  • However, usage patterns ranged from “limited”
    to “required cues to use”.
• Most of the patients used more than one
  communication method
• Increased patient initiations were
  associated with availability of the VOCA
Observed VOCA Messages
 “I love you”  = 9
 FAQs (go home, restraints, breathing
 tube) = 4
 Anxiety/worry/ fear = 4
 Pain = 3
 Comfort (thirst, position, cold) = 3
 Family =1
     Novel Scenarios in which MICU
        patients used VOCAs to
1.   Informed consent – to participate in
     research & diagnostic testing
2.   Semantically complex message
3.   Patient initiated messages
        What is your religion?
        Is the house clean?
        I want my sister!
Patient ratings of “Ease of
 Communication” increased
 significantly in the VOCA versus no
 VOCA (pretreatment) condition.
        Anecdotal Reports of
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.
Suggested Design Improvements
     Larger screens
     Greater touch sensitivity
     Easier keyboard access (DynaMyte)
     Simplier – less expandable (DynaMyte)
     Realtime Tracking/Storage of Messages
     Backlighting (MessageMate)
   poor positioning/out-of-reach
   UE weakness
   blurred vision
   fluctuating cognition/attention
   deterioration in condition
 Staff time constraints
 Lack of knowledge about device
 Device complexity
It 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
    Partner Behaviors that
    Facilitated VOCA use
   Cueing patients in selection of
   Repositioning patient or device
   Aids: glasses, hearing, access tools
   Patience with slow message
   Improved condition and UE strength
What we learned about AAC…
   Start simple
   Basic instruction card
   SLP support
   Tech support
   Partner training
What we learned about AAC…

 Use progressive, expandable
 Capitalize on combined methods
 Cueing
 Consistency
 Repeat instructions
For 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.
      Part IV
Introduction to the
 SPEACS Project
Time for a large-scale study…
        • A “large n” study across multiple ICU
        • Planned prospective design with 3
          patient/nurse cohorts
        • Treatment: A systematically
          designed AAC and basic
          communication intervention
          “package” implemented by nurses
          and an SLP
        • Quantitative analysis of the
          INTERACTIONS between the
          nonspeaking patient AND the
          primary nurse caregiver
Study of Patient-Nurse
Effectiveness with Assisted
Communication Strategies
Multidisciplinary Research Team
       Mary Beth Happ, Ph.D., R.N.
     Kathryn Garrett, Ph.D., CCC-SLP
           Susan Sereika, Ph.D.
      Elisabeth George, Ph.D., R.N.
          Michael Donahoe, M.D.
          Judith Tate, M.S., R.N.
   School of Nursing University of Pittsburgh
              Duquesne University
    University of Pittsburgh Medical Center

     Expert consultants:
     Maria Connolly, B.S.,R.N. -- Loyola University
     Melanie Fried-Oken, Ph.D., CCC-SLP -- OHSU
     Neville Strumpf, Ph.D., R.N. -- U. of Penn
  5-Year Funding (2003 -- 2008):
National Institute of Child Health and
 Human Development (NICHHD)
  “Improving Communication with
 Nonspeaking Patients in the ICU”
 Background and Rationale
 Research Questions & Study Aims
 Research Design & Model
 Independent Variables: Description of 2-
  Phase Intervention Packages
 Procedures
 Dependent Variables/Data Collection
 Data Analysis
 Potential Challenges
 Invitation to Comment
 Definition of Augmentative &
 Alternative Communication
All communication methods that
supplement natural speech including
unaided (signing, vocalizations) or aided
(writing, typing, electronic device)
          - from Beukelman & Mirenda, 1998
   Natural Approaches
 Mouthing words

 Writing

 Gesture
• 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 tube
      • Writing: Paper/pen is not made available, the
        patient is illiterate, or upper extremity function is
      • Gestures: 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
      • Rate: Message co-construction can be a slow
Prosthetic Oral Approaches

 Tracheostomy one-way speaking valve
 Aided Strategies:
Low tech symbol boards/
    direct selection
            Electronic VOCAs

               • synthesized or digitized
                 voice output
               • symbolized messages
               • multiple level option
               • scanning option

                        Message     TM

• AAC is not considered “customary care”
  • Nurses do not have easy access to AAC
  • Nurses do not receive training in their use
  • Natural communication strategies and/or AAC
    technologies are not applied systematically to
    all conscious ICU patients
  • Communication strategies are not
    individualized for specific patients
  • Ongoing consultation about communication
    strategies typically is not available for nurses
    in the ICU
Study of Patient-Nurse
Effectiveness with Assisted
Communication Strategies
        RQ/Specific Aim #1
What is the impact of two experimental
     (1)Basic Communication Skills Training
        (BCST) for nurses
     (2)AAC techniques and education +
        individualized SLP consultation
…on ease, quality, frequency and success of
nurse-patient communication?
     RQ/Specific Aim #2

How do interactions in the two
communication intervention conditions
(BCST and AAC-SLP) compare with
those in a control (usual care) cohort?
Research Model

                     BCST                     AAC/SLP

Voiceless                 Communication                   Nurse
Patient                      Process


                Success             Quality
                           Ease               Frequency

Happ, M.B. & Garrett, K.L. (2003)

AAC-SLP > BCST > Control on:


 of nurse-patient communication interactions.
Research Design
Nonconcurrent Cohort Design
  with Repeated Measures

 Year 1         Year 2          Year 3
  Control        BCST           AAC-SLP
T1 T2 T3 T4   X1T1 T2 T3 T4   X2T1 T2 T3 T4
       2 Settings
• Medical ICU
• Cardiothoracic ICU
Condition 1 - Usual Treatment
• No specific communication training for
• Communication interaction and
  intervention at the discretion of the
  patient or untrained nurses
        Condition 2 -- BCST
• Training for nurses in basic communication
  skills prior to data collection
• Delivery:
  • 2 hour inservice (instruction &
    roleplay) with SLP <2 months prior
    to data collection
  • Website consistently available
Sample Basic Communication
• Approach patient
• Alert patient (“George…”)
• Tag yes/no questions (“Yes…or No?”)
• Provide auditory or written choices
• Ask open-ended questions when appropriate (“Tell
  me what’s on your mind.”)
• Instruct patients to use specific natural modalities if
  they do not initiate
      • Show me one of the gestures we talked
      • Write it for me.
      • Can you mouth the words more clearly?
   Condition 3 -- AAC + SLP
• Incorporates basic communication skills
• SLP 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 appropriate
• SLP is available on an ongoing basis to
  consult with nurse about communication
          Nurse Sample
     (quasi-random selection)
 5 RNs/unit = 10 RNs x 3
 = 30 RNs
  RN Entry Criteria:
   1-year critical care experience
   Full-time staff, not permanent night
   Selected from pool of volunteers
             Patient Sample
    3 pts/RN = 30 pts x 3
        90 patients
      =Entry Criteria:
• Respiratory intubation
• Likely to remain intubated for a min of 48 hrs
• Understand English
• Glasgow Coma Scale > 13
Exclusion :
• Premorbid inability to communicate verbally or
  nonverbally (a score of <3 on the NOMS cognition,
  expressive, and receptive language subscales
• Delirium or limited movement OK
         Data Sources
• Transcriptions of videorecorded
  nurse-patient interactions
  • 3 minute segments -- 2x/day for
    2 days for each nurse/patient
• Observer ratings
• Field Notes
• Clinical record/chart
• Videotapes of the 2-minute nurse/patient
  interactions will be transcribed and coded for
  the following variables:
   • How frequently did the patient initiate
   • 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?
Observer Ratings of Ease of
                     Eas e of Communication Observer Rating

 1. Overall how difficult was it for the patient to communicate with the nurse?

 Not difficult <1       2       3       4       5       6           tremely Difficult
                                                                7> Ex
 at all

 2. How difficult was it for the patient to communicate physical needs (such as
    being suctioned, being turned, etc.)?

 Not difficult <1       2       3       4       5       6           tremely Difficult
                                                                7> Ex
 at all

 3. How difficult was it for the patient to communicate thoughts and feelings?

 Not difficult <1       2       3       4       5       6           tremely Difficult
                                                                7> Ex
 at all

 4. Overall the nurse appeared to feel ________ a t the end of the interaction

 Calm/satisfied <1          2       3       4       5       6     7>Frustrated/angry
• Field Notes will also be compiled
  for qualitative analysis of:
  •   Setting variables
  •   Topics
  •   Affect
  •   Unusual circumstances
  •   Presence of restraints
  •   Patient’s cognitive status
  •   Etc.
         Data Sample
4 observations/pt x 30 pts/phase
 = 120 observations/phase
 x 3 phases

 360 observations
• Will specific patient or nurse variables
  explain/predict patterns in the data?
• Patient Co-variates
  • Gender
  • Type of ICU
  • Premorbid communication ability
     • Measured by subscales of the NOMS
  • Severity of Illness (APACHE)
  • Length of Intubation prior to study
  • Degree of Agitation (CAM-ICU)
  • Degree of Sedation (RASS)
  • Motor Ability (Lowenstein)
• Nurse Co-variates
  • Total nurse contact time with patient
  • Time elapsed since training
  • Critical care experience

                  BCST                        AAC/SLP

Voiceless                    Communication                    Nurse
Patient                         Process
    Level of Consciousness                         Nurse Contact Time
       Illness Severity                        Time Elapsed Since Training
      Communication Fx
            Motor Fx           Outcomes

              Success               Quality
                             Ease               Frequency
        Data Analysis (S.S.)
•   Exploratory data analysis
•   Hierarchical generalized linear
    modeling (HGLM)
•   Linear contrasts based on
•   Model assessment (i.e., residual
    analysis and evaluation of
    outlier/ influential observations)
 Potential Problems & Solutions
• Brief ICU stays/2 day data collection period
• Variable nurse scheduling/ day nurses only,
  request same patient
• Fluctuation in patient condition/ track delirium and
  severity of illness as a co:variate
• Diffusion of the intervention/ assess in 2 ICUs,
  use 3 separate cohorts
• Measurement intrusiveness and complexity/ extra
• Is 2 days enough time to develop an effective
  communication intervention?/ oh well -- it
  represents the real life challenge!
                  Our timeline
• January 2004:    Final Instrument Development &
                   Pilot Testing of Procedures
• March 2004:      Nurse/Patient enrollment for
                           Usual Care Condition
• March 2005:      Begin BCST Condition

• January 2006:    Begin AAC-SLP Condition

• January 2007:    Data Analysis

• July 2008:       Complete Data Summarization
Questions and Comments
   from the Audience
• Please cite information from this
  presentation as follows: ******
• Correspondence:
  • Mary Beth Happ, Ph.D., R.N.
     • University of Pittsburgh
  • Kathryn Garrett, Ph.D., CCC-SLP
     • Duquesne University