Download Communication Access Within Medical Settings

Communication Access Within Medical Settings
By Harvey Pressman and Emily Newman (Central Coast Children’s Foundation)
and Juli Pearson, MS,CCC-SLP (Boulder Community Hospital)
Introduction
In health care settings, communication breakdowns between patient and caregiver can
have dire consequences: increased patient pain, misdiagnoses, drug treatment errors, unnecessary
extensions in length of hospital stay, even death. In a six-year (1997-2002) study of the root
causes of “sentinel events” in hospitals, the Joint Commission on Accreditation in Health Care
Organizations (JCAHO) in fact placed “communication” at the very top of the list of root causes.
The sad fact is that, although there now do exist a set of simple tools and strategies that can
quickly and effectively improve communication between patients/family members and
caregivers, these tools usually go unused and ignored in most health care settings. Useful
information about these tools and strategies is, moreover, scattered among a variety of disparate
sources and, in a few cases, not readily available or accessible.
Communication difficulties are all too often devastating In health care settings. They can,
and often do, create huge barriers between patients and health care staff. Trouble
communicating can be attributed to new or chronic speech and/ or comprehension difficulties,
medical interventions and/or language barriers of non-English speakers. Patients regularly report
instances in which communication barriers result in feelings of anxiety, fear, frustration,
unrecognized pain, and overall loss of control.
Augmentative and alternative communication (AAC) tools and strategies, and other
assistive technology (AT) techniques and products, can ease communication between patients
and health care providers, allowing patients to participate more fully in their care. Although,
when we think of these devices, we often think of fancy high-tech equipment, these
communication interventions range from no technology (e.g., gestures and signs, alphabet
boards) to “low” technology (e.g., communication boards and wallets) to high technology (such
as voice output communication aids). Unfortunately, these techniques are most often underused
in healthcare setting because of lack of knowledge about and/ or access.
Boulder (CO) Community Hospital has developed a program focused on utilizing lowcost, easy to use tools to meet communication needs. These communication needs include
patients with limited verbal and/or written communication, hearing loss, and/or those who speak
English as a second language. This novel program also includes low cost and easy to use tools
that speech therapists have access t, in order to evaluate patients and provide individualized
communication options for more complex communication needs.
Many patients may enter the hospital in a “communication vulnerable” state, or become
so by virtue of their condition or treatment. (We have borrowed this term from “Improving
Patient-Provider Communication: A Call to Action.” by Patak, Wilson-Stronks, Costello,
Kleinpell, Hennerman, Person, and Happ. [Manuscript submitted]) Take the example of people
rushed to the hospital without their glasses or hearing aids, and then expected to answer various
questions that they can’t hear, and sign consent form they can’t see, on top of the stress of their
current condition. In some cases, patients’ communication abilities are weakened due to trauma,
decrease in health or discomfort and pain. For example, people on ventilators cannot speak their
requests. Because they are in a weakened state and have IVs in place, writing becomes difficult
and requires too much effort. In such sub-optimal situations, patients are faced with critical
decisions. They need to be able to communicate fully with their health care providers to ensure
receipt of effective care. In one study (Patak et al., 2006), 62% of patients reported high levels of
frustration associated with their inability to communicate effectively during mechanical
ventilation, and thus their needs not being met. In the general hospital setting, also, there is often
a friend or family member who usefully serves as a communication conduit between the
professional staff and the encumbered patient. However, when that person goes home for the
evening or is otherwise not present, the patient can be left without the tools to communicate and
this is highly distressing for many patients. For elderly patients these circumstances may lead to
disorientation and to the need for medication which may not otherwise be needed.
The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO)
strongly emphasizes (Standard of Care RI.2.100) that “The patient has a right and need for
effective communication” (http://www.jointcommission.org/). Specifically, the Elements of
Performance for RI.2.100, No. 4 state, "The organization addresses the needs of those with
vision, speech, hearing, language, and cognitive impairments." Additionally, the 2007 National
Patient Safety goals include (2007 National Patient Safety goals- Goal 13) encouraging
“patients’ active involvement in their own care,” which requires overcoming communication
barriers
(http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/07_bhc_npsgs.htm).
Furthermore, patients with access to communication receive less sedation, are transitioned faster,
have less pain have increased satisfaction with their care, feel more in control and generally do
better.
Psychiatric hospitals present another special set of needs. Psychiatric hospitals depend on
a number of formal group settings, individual interviews, and availability of nursing staff for ad
hoc patient initiated approach and communication. When patients are encumbered through
specific handicaps such as language or sensory difficulties, the entire treatment process is
jeopardized. In addition, some patients because of their very psychiatric illness are impeded
from fluid verbal communication but may be able to communicate in writing or drawing. Failure
to ensure communication in these situations has directly led to treatment failure.
Since so many hospitals lack vital knowledge and resources on incorporating
communication access tools into their patient care systems, the Central Coast Children’s
Foundation has compiled this guide of available sources of such information for hospitals.
Getting Communication Access Tools to Patients
Working at a community hospital in Boulder, CO, speech language pathologists Juli
Pearson and Debby McBride have developed a communication tool kit program to help mediate
communication barriers (due to language issues, ventilators, hearing issues, etc.) in the hospital
setting. Their materials includes two tool kits, a resource book, a streamlined reordering system,
‘how to’ books, and a variety of training resources. One of the tool kits has been particularly
helpful hospital-wide, and each nurses unit has its own tool kit for quick access. This On the
Spot Communication Toolkit includes:
9 word boards and picture boards (in various languages)
9 a modified call bell (to help people who can’t use a regular call be to get help),
and “how to” instructions with easy to follow pictures
9 a pocket talker amplifier (for people who left their hearing aids at home and/or are
having trouble in a noisy hospital environment)
9 writing boards complete with “Writing Strategies” to help patients write when
they can’t speak and have physical limitations
9 a magnification glass for people who don’t have their glasses and need to read
consent forms
9 English-to-Spanish translation cards for nurses to use
9 …and other tools useful to patients and staff (e.g. “a hearing aid trouble shooting
guide”).
Pearson and McBride based the development of their tool kits/ program on a hospitalwide needs assessment, review of research in the field, and current nation-wide hospital
standards (JCAHO). There are no tool kits currently on the market such as the ones their
hospital is currently using. They have presented on their tool kits at several conferences and
workshops, and the feedback they keep getting is that many people would like these available to
them, as clinically many others in the field recognize their usefulness and have experienced the
challenges of keeping items like this on hand when needed. Debby McBride and Juli Pearson are
now expanding these tool kits, trainings and resources to other hospitals nationwide under the
name “On the Spot Communication” tools. For more information go to
www.aactechconnect.com.
Within the program developed by Juli and Debby at Boulder Community Hospital, there
are three primary methods of getting communication access tools to patients: (1) addressing
basic needs through their On the Spot Communication Toolkit, with simple, easy-to-use tools
that all staff has access to, (2) addressing complex communication needs through an AAC
evaluation kit specially designed for the hospital population, which is used by SLP’s and (3)
providing for ongoing communication needs through a communication access tool loan bank,
and/or giving away low-cost communication access tools.
The On the Spot Communication Toolkit meets immediate basic communication needs
and includes comprehensive tools for vision, speech, hearing, language and cognition, as well as
tools for non-English speakers. Boulder Community Hospital found that it was critical to have a
toolkit for each nurses unit to provide quick easy access to tools and to make staff accountable to
regularly use the tools and restock their kits. The more often the kit is used, the more likely it is
that staff will use the kit again, thus benefiting more and more patients. Also, BCH has found
that the labeling and restocking system are both critical for success, in order to have tools
accessible when they are needed, as well as for proper infection control. Some hospitals, with
the best of intentions, have purchased a one-time stock of tools, which will work for a while, but
unless there is a central location (such as a toolkit), labels on all tools to help ensure that the tools
get back to the correct location, and a easy way to restock the tools, there will be a much lower
success rate.
For individuals who have more complex communication needs in the health care settings,
a speech language pathologist should be called on to help determine what tools may or may not
work for a patient. One of the problems that often arises is that most SLP’s in the hospital
setting have an expertise in diagnosing and treating dysphagia and cognitive communication
disorders, but do not necessarily have an expertise in Augmentative and Alternative
Communication. Alternatively, a SLP who has AAC expertise often times have more experience
and expertise with the outpatient population, whom has significantly different demands and
medical stability than the patient in more of an acute setting. At Boulder Community Hospital,
Juli Pearson and Debby McBride recognized these issues, and complied an On the Spot
Assessment Toolkit for SLP’s. This toolkit includes a way for therapists to quickly and easily
assess and address complex communication needs. The focus is on providing simple to use tools
that are easy for family, patients, and nursing staff to set up and use. The assessment kit includes:
9 Assessment Hierarchy
9 Evaluation Form
9 Resource Notebook with CD for reprintable pages: organized into the following sections:
o Alphabet and Words (letter boards, key guard, word board/topic boards, etc. )
o Pictures and Symbols (Vidatak/Children’s Hospital of Boston Picture Board,
other picture boards, photographs, life images…)
o Spanish Boards (Vidatak EZ board, picture communicator, daily communicator)
o Modifications (simple voice output devices [Go Talk, Talking Photo Album],
adaptive call bell, eye gaze/partner assisted scanning, amplification)
o Bedside Recommendations (strategies that can be posted for family/ staff
education)
9 Tote Bag with Assessment Tools (that match our resource book)
Lastly, for patients with ongoing communication needs, an AAC Loan Bank and/or
“Give-Aways” can be incorporated into hospital care. Many low-tech and no tech
communication access tools cost between $10 and $200 and are usually not covered by medical
insurance. As many patients do not have money with them when they enter the hospital or do
not have family members present, they are not always readily able to purchase the low-cost but
essential communication tools upon discharge. Patients are also not used to buying items for
their own care in a hospital setting. Take one example of a patient who needs a tracheostomy
tube to breath. They do not have to pay cash for this before leaving the hospital with it, as it is
critical for their care. Communication is also a critical part of care; thus, it is inequitable to
require patients to pay for a communication tool upon leaving the hospital in order for them to
leave with it. One of the problems that therapists run into is that once a patient leaves with the
communication tool, the tool is no longer available for other patients to use. Thus there needs to
be a loan/ “give away” bank of tools for patients to use and take as needed. Boulder Community
Hospital was able to find funding for these tools through an annual grant from its foundation and
auxiliary board by applying for a simple grant and presenting the idea. They have subsequently
received funds from several grants which allow them to restock the items periodically.
Ideally, the overall costs of tool kits should be distributed throughout a hospital so that
the cost that doesn’t burden one department or another. Before the program was in place at
Boulder Community Hospital, all communication tools and resources came from the Speech
Therapy Department. This not only burdened the Speech budget with staff and resources, but
also led to patients’ needs slipping through the cracks. Now that the program is underway, each
nursing unit has an tool kit which has been incorporated into their budget. They have received
hospital grants from their foundation and auxiliary board to pay for “give away” tools; and the
speech evaluation kit has been incorporated into the rehab budget. Distributing the cost and
responsibility has created more ‘buy-in” for the communication tools among all staff and led to
increased hospital wide efforts meet JCAHO standards, and more importantly, communication
needs.
Gaining Administrative Support
Communication access in the health care setting must be functional, user-friendly,
accessible and easy to acquire. To gain administrative support within a hospital, Juli Pearson
and Debby McBride found the following steps beneficial:
9 collaborate with a Patient Care Representative who mediates JCAHO standards,
patient feedback, and advocates for patient rights and communication
9 incorporate access to communication tools as a policy standard vs. a “gold star”
(e.g., JCAHO standards, meeting the needs of non-English speakers, patients who
are Hard of Hearing, etc.)
9 conduct a needs assessment with staff and representatives of each clinical
department (nurses, therapists, interpreters, etc.)
9 solicit patient feedback
Boulder Community Hospital gained vital administrative support to address the
communication access needs of patients and now runs a successful program in which
communication access is effectively addressed, enabling health care providers to supply valuable
and more complete care.
At Boston Children’s Hospital, John Costello has helped create one of the first dedicated
AAC services in ICU and acute care services, which has been an established inpatient service
since 1992 (cf., Costello, J. “AAC intervention in the intensive care unit: The Children's Hospital
Boston model”, Augmentative and Alternative Communication, Volume 16, Issue 3, September
2000 , pages 137 - 153). Costello provides leadership for efforts that focus on all patients who
are ‘communication vulnerable’ in the hospital setting, which have earned growing
administrative support. This includes not only people who may be congenitally or temporarily
nonspeaking, but also includes those who can not speak English and those who can not access
the communication tools (standard or adapted) that are available, such as nurse call.
Boston Children’s has a long history of a model of intervention, including a pre-op model
of voice and message banking. Their inpatient AAC service focusing on all patients who are
communication vulnerable has been internationally recognized as a ground-breaking service.
Further, it has been a featured service when Children's Hospital Boston has conducted intensive
hospital wide 'show cases' of best practices for national and international visiting medical center
personnel who wish to duplicate their models of patient care and service delivery.
Due to increased demand for such services, Boston Children’s is now dedicating an FTE to
do ONLY inpatient AAC (prior to that, the full service was provided, but it was by an outpatient
clinician who 'doubled up' and had a massive volume/productivity). They have added a second
dedicated AAC inpatient SLP, with administrative support for more than a decade. The hospital
has provided funds to purchase all of the inpatient devices/switches/printer cartridges/laminate,
etc.) since 1994. The ICU alone has had a dedicated line item for AAC equipment since 1997.
The Neurosurgery program has supported the use of AAC equipment since 1998.
Anesthesiology has worked with Costello to have a budget for AAC switches, nurse call
adaptations, mounting arms and med administration pump switch access for more than a decade.
Children’s also has an established AAC program for working with people at the end of
life, and, since 2001, a formal program with Dana Farber Cancer Institute. Further, the hospital
board of directors has recognized the need to allocate funds received as 'gifts' directly to
supporting the materials ranging from printer cartridges to dedicated AAC devices. Each year,
Costello has received a generous capital budget approval for AAC devices, equipment, etc.)
Costello’s focus has been on promoting institutional wide awareness of what “communication
vulnerable” means, and how it may negatively impact outcomes. Going hand in hand with this is
a clearer picture of the value added by the SLP who can do an AAC feature match to patient
needs, and then implement and train appropriate AAC strategies. Costello is also seeking to
utilize a nurse teaching and assessment tool developed by Lance Patak that will focus on
recognizing what “communication vulnerable” means.
Communication Access Resources that Can Be Used in a Hospital Setting
There are many resources to assist clinical staff in determining which tools or devices to
utilize for communication vulnerable patients. This section provides various books, articles and
websites which can easily be accessed to provide information on communication strategies
within hospital settings..
Books:
In 2007, Augmentative Communication Strategies for Adults with Acute or Chronic
Medical Conditions was released. This book, edited by David Beukelman, Kathryn Garrett and
Kathryn Yorkston, is a compilation of practical “how to” information drawn from 23 well-known
AAC clinicians and researchers. There is also an accompanying CD with clinical forms and
strategies. For more information see http://www.amazon.com/Augmentative-CommunicationStrategies-Chronic-Conditions/dp/1557668752 .
Another book edited by David Beukelman and Kathryn Yorkston, as well as Joe Reichle,
Augmentative and Alternative Communication for Adults with Acquired Neurological Disorders,
addresses recent social, medical and technical changes and how they affect adults with
communication disorders. Part I discusses the everyday transition issues patients struggle with –
such as establishing new communication roles and integrating their natural speech with AAC –
while Part II covers the six leading neurological disorders in adults: amyotrophic lateral
sclerosis, Huntington and Parkinson’s diseases, traumatic brain injury, aphasia and dementia.
For more information, please see the following web link:
http://www.brookespublishing.com/store/books/beukelman-4730/index.htm.
The Handbook of Augmentative and Alternative Communication, written by Sharon
Glennen and Denise C. DeCoste, provides a comprehensive and practical guide for people
working with those who do not communicate vocally. The book can be found at
http://www.amazon.com/Handbook-Augmentative-Alternative-CommunicationGlennen/dp/1565936841. Chapter 16 of the handbook, entitled “AAC in the Hospital Setting” is
especially relevant and can be previewed on Google Books at the following link:
http://books.google.com/books?id=ylHxZMRseFgC&pg=PA603&lpg=PA603&dq=aac+hospital
s&source=web&ots=Wq3VvqSKkx&sig=KDKcUwj_L2S-Vb1cA0EQAdpCPNg&hl=en.
Jerome Groopman recently wrote a book about what goes on in a doctor’s mind as he or
she treats a patient. Entitled How Doctors Think, Groopman’s book was recently reviewed in the
New York Times. These reviews, and a first chapter that starkly illustrates the potential life and
death significance of doctor:patient communication can be found at the following links:
http://www.nytimes.com/2007/04/01/books/chapters/0401-1stgroo.html?_r=1&ref=firstchapters&oref=slogin and
http://www.nytimes.com/2007/04/01/books/review/Crichton.t.html.
Articles:
A recent newspaper article entitled Hospital Picture Boards Break Language Barriers:
More States to Introduce Panels that Boost Care of Non-English Speakers discusses the positive
impact that emergency room picture boards have had for patients who do not speak English.
Utilizing picture boards is an effective communication method for non-English speakers to
describe their ailments to emergency medical staff. While in this case the picture boards are
utilized in emergency rooms, they can also be utilized in other medical settings to ease
communication barriers for patients. The boards originated in Florida after Hurricane Andrew in
1992 and have gradually caught on by word of mouth among health groups in various states. To
see the full article, please go to http://www.msnbc.msn.com/id/20588960/. Richard Hurtig and
Debora Downey have shared their interesting presentation on “The Use Of Augmentative &
Alternative Communication In Acute Care Settings” at the Iowa Speech and Hearing
Association conference in October, 2006 on line at
http://www.uiowa.edu/~comsci/research/speechlab/powerpoints/Implementing.pdf. (See
also “Communicating with People Who are Deaf or Hard of Hearing in Hospital Settings,” an
ADA brief @ http://www.ada.gov/hospcombrscr.pdf)
Patient communication may also face obstacles due to long-held practices regarding
physician communication around “adverse events.” A March/April, 2008 article in Harvard
Magazine points out that it is difficult to overestimate how ingrained the old way of doing things
is in doctors’ psyches: “This is shameful to say, but in many circumstances, the advice was ‘Do
not talk to the family at all’—period,” says Robert Truog, professor of medical ethics at Harvard
Medical School (HMS). “You can imagine a physician or a nurse, who is feeling horrible about
what’s just happened, being told by attorneys not to have any communication. You can imagine,
from the family’s side, how horrible it is to have had a relationship with the doctor or nurse, and
to suddenly have that completely cut off. That was standard practice until recently.”
Last year, Truog, who also directs the Institute for Professionalism and Ethical Practice
at Children’s Hospital Boston, helped design a program that trains doctors to have
conversations of the kind Leape advocates. Employees of Beth Israel Deaconess Medical Center
and Brigham and Women’s Hospital have gone through the training. The curriculum grew out
of “Difficult Conversations,” a more all-encompassing program on doctor-patient
communication that Truog and Browning had developed. Typically, young physicians and nurses
learn how to deal with patients and families through trial and error, Truog says. “The damage
that can be done there is just as real as the damage that can be done by not being adequately
skilled at a procedure.”
Communication between and among hospital staff members is another problem that can
impact importantly on patient care and be enhanced by the right tools. To streamline the
communications process and improve patient care and satisfaction, the University of Kentucky
Hospital Emergency Department installed the Vocera Communications system in March 2004.
This device, a small wearable badge that enables instant voice communication over a wireless
network, enables health care personnel to immediately reach and respond to their colleagues.
This system helped improve communication for staff and ultimately improved patient care. For
more information, click on the link below:
http://www.uky.edu/PR/News/Archives/2004/April2004/040428_vocera_communications.htm.
Websites:
AAC TechConnect is a unique website that connects AAC devices with individuals while
promoting independence through Augmentative Communication. This unique website enables
clinicians, AAC users and medical staff to stay up to date on new AAC devices, provides contact
information for all major AAC manufacturers, details product information for nearly 100 AAC
devices, provides free trials of AAC devices and facilitates an easy search for AAC devices,
comparing features of roughly 100 devices. For more information, see the AAC TechConnect
website at: http://www.aactechconnect.com/index.cfm.
Manufacturers and Vendors of Communication Supports
There are various manufacturers of devices that can support communication access in
hospital settings. Juli Pearson and Debby McBride are in the process of consolidating their
program resources, kits and training tools into a format that can be purchased and marketed for
use in other hospitals and health care settings, as well as a kit for disaster relief preparedness.
Please contact them with interest and or questions (emails below). Below is a list to assist
medical practitioners in identifying and obtaining useful communication devices. (It may be
possible for AACTechConnect to provide all of these items from a single source, if desired.)
Vidatak E-Z Communication Boards
(Multiple languages and Picture board )
VIDATAK, LLC, (877) 392-6273 or 877 EZ BOARD Picture Board
www.vidatak.com
Critical Communicators / Pocket Communicator/Picture Communicator (multiple
languages)
Interactive Therapeutics, (800) 253-5111
[email protected]
WordPower OnBoard
Saltillo Corporation, (800)382-8622
www.saltillo.com
Communication Boards / books (blank)-847-816-858
Mayer-Johnson, LLC, (858)550-0084
www.mayer-johnson.com
ABC Overlay with keyguard
AAC TechConnect
www.aacTechconnect.com
Email: [email protected]
Buddy Boards (Alphabet Board w/keyguards & phrases)
Buddy Speak, LLC
www.BuddySpeak.com
Spanish learning websites for first responders:
http://www.spanish4emergencies.com/
www.SpanishOnPatrol.com
PockeTalker (for hearing impaired)
Williams Sound products from A Bridge Between Nations
(888) 432-0874 or (928) 526-1591
E-mail: [email protected]
Chattervox (voice amplifier)
Asyst Communications Co., Inc., (847 ) 816-8580
www.chattervox.com
U. S. Census I Speak card
http://www.usdoj.gov/crt/cor/Pubs/ISpeakCards.pdf.
(“Mark this box if you speak --------, “ written in 40 different languages.)
Kwikpoint Medical Translators
1-888-594-5764
http://www.kwikpoint.com/
(Medical Visual Language Translator, critical-care English-Spanish picture panels, Disaster Assistance
Translator, eight languages)
Eyelink board & instructions
CINI, (631) 878-0642
www.cini.org
Go Talk communication devices /Health Care Communication Board
Attainment Company
(800)327-4269
www.attainmentcompany.com
iCommunicator
718-965-8600,
http://www.icommunicator.com/
(Converts speech to text, speech to video sign language, and speech to computer-generated voice
or video sign language.)
Medical Buddy Board System
1-866-942-9200
http://www.buddyspeak.com
(This non electric communication board was designed to help facilitate communication in patients who
have lost the ability to speak due to an injury or condition such as a tracheotomy. The patient can point to
letters and watch as someone else types and sentence recorded.)
.
Talking Photo Album
Augmentative Communication, Inc., (831) 649-3050
www.augcominc.com
For more information on the Boulder project, contact Juli Pearson at
[email protected] and/or Debby McBride at [email protected].
For an electronic version of this web essay, contact [email protected].
COMING SOON: www.patientprovidercommunication.org
Copyright 2008, Central Coast Children’s Foundation, Inc. (www.centralcoastchildrensfoundation.org)