No Longer Voiceless in the ICU Speech-language pathologists and intensive care nurses help intubated patients communicate. On the Pulse
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On the Pulse  |   December 01, 2017
No Longer Voiceless in the ICU
Author Notes
  • Kate Holden, MS, CCC-SLP, has worked as a clinician in the acute-care setting at Johns Hopkins Hospital in Baltimore for six years. She works in the neuroscience department, specializing in the neurological and neurosurgical population, with a special interest in language and communication disorders in critically ill patients. kholden4@jhmi.edu
    Kate Holden, MS, CCC-SLP, has worked as a clinician in the acute-care setting at Johns Hopkins Hospital in Baltimore for six years. She works in the neuroscience department, specializing in the neurological and neurosurgical population, with a special interest in language and communication disorders in critically ill patients. kholden4@jhmi.edu×
Article Information
Healthcare Settings / On the Pulse
On the Pulse   |   December 01, 2017
No Longer Voiceless in the ICU
The ASHA Leader, December 2017, Vol. 22, 40-41. doi:10.1044/leader.OTP.22122017.40
The ASHA Leader, December 2017, Vol. 22, 40-41. doi:10.1044/leader.OTP.22122017.40
Have you ever been in another country and not spoken the language? How frustrated and vulnerable did you feel when you couldn’t communicate your basic wants and needs, much less more complex messages? This is the experience of our intubated patients in the intensive care unit (ICU) every day.
I have worked for six years in the Neurology Critical Care Unit (NCCU) of a large teaching hospital. I work primarily with patients who have neurological or neuromuscular disorders or who have had cervical and brain surgeries. When I first began working on the NCCU, speech-language pathology was consulted primarily for swallow evaluations or for speaking-valve evaluations for patients with tracheostomies. We rarely worked with patients who were orally intubated.
However, I began to notice patients who were intubated, alert and trying (often unsuccessfully) to communicate with their nurses or loved ones. More nurses were seeking me out to ask for communication boards. In a rush, I would print off small black-and-white boards to give to patients until I could go to my office to get a larger variety of communication boards. This delay meant additional time that patients were unable to successfully communicate their needs.
Panic and frustration
I researched communication in the ICU and learned some startling facts. Studies show that difficulty communicating is the most commonly distressing symptom of mechanically ventilated patients (see sources). It produces panic, terror, stress, frustration, anxiety, dehumanization and sleeplessness in the ICU. And, with an increased push in the ICU to decrease patients’ sedation levels and increase mobility, more patients are awake and alert while intubated.
So, communication remains a challenge for intubated patients. ICU staff may not know about or be trained in augmentative and alternative communication (AAC) and communication strategies, or they may have limited access to appropriate materials. They may not ask speech-language pathology for an evaluation of communication needs. And even though nurses play an essential role in establishing communication with patients, studies show that nurses often report feeling unprepared to effectively communicate with patients with complex communication needs (see sources).

Studies show that difficulty communicating is the most commonly distressing symptom of mechanically ventilated patients.

What to do
I began to wonder what I could do to help improve communication in this fragile population in our ICU.
I found a research study led by MaryBeth Happ, a nurse from the University of Pittsburgh, that answered my question. She found that nurses’ attitudes and practices related to communication with nonverbal patients improved after completing a basic communication skills training program.
Together with the support of the nurse manager and nurse educator, we decided to implement an adapted version of Happ’s program with our NCCU nurses. I led the program with NCCU staff support and, because it has been successful, we expanded it to other units in our hospital, including the surgical ICU and oncology ICU. On each service, the primary speech-language pathologist leads the program with nursing leadership support.
Our program had three parts. First, nurses took Happ’s one-hour online course, SPEACS (Study of Patient-Nurse Effectiveness with Assisted Communication Strategies), which discusses simple strategies to improve communication with nonverbal patients. (The $15 class is worth one continuing education unit for nurses.)
Next, we assembled a “communication cart” and placed it in a visible and easily accessible location on the NCCU. The cart was equipped with simple communication tools and low-tech AAC. Tools include clipboards, notebooks, dry-erase boards, markers, felt-tip pens, hand grips, magnifying glasses and door signs that indicate what strategies patients are using to communicate. Lo-tech AAC includes alphabet boards, letter boards, word boards, picture boards, pain scales and eye-gaze boards. The rehab department paid for the initial cart materials (about $100) and the NCCU maintains it.
We gradually added other materials to the cart to meet the needs of our patients: procedures boards with images of upcoming procedures, patient interview questions to give nurses topics to talk about with their patients, and communication boards in languages other than English.
In the third part, I provided short (five-minute) in-service trainings to nurses, respiratory therapists, clinical technicians and social workers twice a week during NCCU morning huddles. We discussed communication strategies, reviewed items in the communication cart, or problem-solved how to communicate with challenging patients on the unit.
Better access
We evaluated the effectiveness of our AAC program by asking staff members to complete 10-item, pre- and post-questionnaires to assess staff attitudes about and competence in communication with nonverbal patients. Nurses took the post-questionnaire three months after program implementation, after the cart was assembled and the nurses had taken the SPEACS course and participated in short, SLP-led communication in-services.
At the three-month mark, nurses and NCCU staff members reported better access to and increased satisfaction with the available tools, and believed their patients were better able to convey basic and complex messages, such as communicating to turn the lights on, turn the TV off, be repositioned in bed, or call family members.
By making simple changes, we were able to change the culture of our ICU to make communication a priority.
Initiating a new program can be a daunting task. Although SLPs understand the importance of communication, its value often does not surface for other ICU staff who are addressing many other complex medical concerns.
Working with nursing staff to implement the program is key to our success. Although the AAC program was initiated by speech-language pathology, we had support from nursing leadership and the program has proven to be successful and self-sustaining. NCCU staff check the cart weekly and restock communication tools, and the SLP restocks the communication boards as necessary. The AAC program has given nursing and other staff the education, tools and strategies to promote improved interactions with nonverbal patients.
We plan to expand the program to all seven of our ICUs to improve the quality of life in our nonverbal patients by providing increased access to communication resources and enhanced nursing education. Improved communication allows patients to be more involved in care decisions, express pain levels more easily and ask the medical team questions. By improving communication in nonverbal patients, we have the opportunity to help them get through very stressful circumstances and be more involved in their medical care.
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1 Comment
December 6, 2017
Marta Kazandjian
Use of eye gaze communication for intubated patients
I have had great success with the use of my EYELINK2 eye gaze communication board available through Northern Speech Services. This has allowed intubated patients as well as patients who are unable to communicate verbally while tracheostomized and ventilator dependent to use their eyes to directly select letters to spell novel messages.
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December 2017
Volume 22, Issue 12