Adult Acute and Intensive Care in Hospitals

Chapter 6 Adult Acute and Intensive Care in Hospitals

Richard R. Hurtig, Marci Lee Nilsen, Mary Beth Happ, and Sarah W. Blackstone

Introduction ments in acute care hospitals diagnose and initiate treatment of acute conditions caused by accidents and injuries, illness, and disease. Acute care hospitals have specialized staff and Many acute care hospitals function equipment to provide treatment to patients like freestanding municipalities because they who present with a broad range of acute and require large, complex infrastructures in chronic illnesses, injuries, and medical condi- order to (a) coordinate the delivery of medi- tions. They vary in size, but all provide care cal care, (b) house and feed patients and staff, on a continuous 24/7 basis. Larger, special- (c) implement medical protocols, (d) manage ized acute care hospitals are sometimes known resources, (e) monitor infection control and as tertiary hospitals. They employ a team of safety issues, (f) maintain administrative and health care professionals, administrators, and financial records, and (g) continually strive support workers and may specialize in trauma to establish and maintain relationships with and the diagnosis and treatment of complex consumers and providers, as well as with out- diseases and conditions. side organizations and agencies. Their funding Health care providers in local or regional comes from different sources, including the acute care hospitals conduct assessments, carry public sector, health organizations (for-profit out procedures, attend to patients and fam- or nonprofit), health insurance companies, ily members, and maintain hospital records patients and their families, and charities. and protocols. Most critically ill patients are Smaller community and rural hospi- housed in intensive care units (ICUs) where tals often provide critical health care access they receive continuous monitoring by critical to local residents and to those living in rural care nurses and a wide range of life-sustaining areas (American Hospital Association, 2013). treatments delivered by interprofessional teams Approximately 35% of hospitals in the United (Fairman, 1992). Less critically ill patients are States are considered rural hospitals. Large treated on “step-down” and general care units, hospitals (≥500 beds) make up only 5% of where the patient-nurse ratio is greater, and the all hospitals in the United States (Centers for intensity of care is reduced. Emergency depart- Disease Control and Prevention, 2011).

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in ensuring that patients are not subjected to The following is an example of the size “avoidable” harm, establishing good lines of and complexity of a large academic communication between patients, health care medical center. The University of Iowa providers, and hospital staff is widely recog- Hospitals and Clinics (UIHC) in Iowa nized as essential. City, Iowa, is the only comprehensive Over the years the University of Iowa academic medical center in the state Hospitals and Clinics (UIHC), the UPMC– and a regional trauma center with a University of Pittsburgh Medical Center, large emergency department. In 2012, Boston’s Children’s Hospital, the Mayo the UIHC employed 1,548 physicians, Clinic, and others have taken proactive steps residents, and fellows, and 6,673 to address the communication needs of their nonphysician employees, including patients more systematically. 1,845 professional nurses. The emergency department had 59,889 patient visits, and there were 32,087 acute care The Importance of admissions. The UIHC has 711 staffed beds, with an average daily census of 544 Effective Patient-Provider patients and an average length of stay of Communication in Hospitals just over 6 days. It also has seven intensive care units with 157 beds (Neonatal Over the course of a day, hospitalized ICU, Pediatric ICU, Medical ICU, patients and family members may need to Cardiovascular ICU, Surgical & Neuro- interact with physicians, nurses, physical science ICU, Burn ICU, and Respiratory therapists, occupational therapists, speech- Services ICU). Patients are typically language pathologists, pharmacists, medical transferred from an ICU to step-down technicians, dietary staff, social workers, pas- units when their status improves, or, toral care providers, housekeeping staff, and conversely, transferred from other care volunteers. The nature of these interactions units to an ICU if their condition deteri- often differs dramatically from the kinds of orates or they require ventilator support. conversations that occur during a routine In 2012, UIHC provided 25,967 days of visit to a doctor’s office or outpatient clinic. ventilator care. For example, hospital-based communica- tions often take place between people who Researchers have repeatedly shown that have recently met or are meeting for the first effective patient-provider communication time, come from very different backgrounds, plays an important role in the medical out- and may be under significant stress and time comes of hospitalized patients, as well as in constraints. Topics discussed during medical measures of patient and caregiver satisfaction, encounters in hospitals often relate to assess- patient safety, quality of care, and utilization ing the patient’s condition, obtaining a health factors (Gallagher, Porter, Monuteaux, & history, reducing pain, administering medica- Stack, 2013; John-Baptiste et al., 2004; Kar- tions, describing and discussing symptoms, liner et al., 2012; Lindholm, Hargraves, Fer- and explaining procedures. These conversa- guson, & Reed, 2012; O’Halloran, Grohn, & tions, while routine to providers, are often Worrall, 2012; Rogers, Martin, & Rai, 2014). unfamiliar and perhaps confusing to patients Because hospitals are expected to be proactive and their families. Adult Acute and Intensive Care in Hospitals 141

In 2012, The Joint Commission, an and comprehended their complaints, symp- accrediting body for hospitals in the United toms, and concerns. Research suggests, how- States, formally recognized the critical nature ever, that this is often not the case, especially of effective communication in hospitals and when patients have disabilities that make it promulgated a set of standards that hospi- difficult for them to speak, write, understand, tals must meet. As shown in Table 6–1, The or remember what providers are saying. Also, Joint Commission Standard Advancing effec- an increasing number of patients do not speak tive communication, cultural competence, and or understand the same language of hospital patient- and family-centered care requires that providers. Patients may come from very dif- hospitals develop ways to identify and address ferent cultural and religious backgrounds, sex- patient communication needs, offer profes- ual orientations, and past experiences. Many sional language access services, deliver infor- patients have limited health literacy and may mation in a manner patients can understand, know little about hospital forms, procedures, provide access to a support person 24/7, and and policies. These patient groups often have collect information on their patients’ language difficulty following discharge instructions, a and communication needs (The Joint Com- major cause of unnecessary hospital readmis- mission, 2010). sions (Alberti & Nannini, 2013; Halverson A common misperception of patients, et al., 2014; Karliner et al., 2012; Lindholm family members, and providers is that com- et al., 2012; Regalbuto, Maurer, Chapel, Men- munication channels work effectively dur- dez, & Shaffer, 2014; Schell, 2014). Also, poor ing medical encounters. Health care team patient-provider communication is a major members may too often assume that patients contributing factor to adverse drug reactions have understood them, and patients tend to after discharge from a hospital (Forster, Murff, believe health care professionals have “heard” Peterson, Gandhi, & Bates, 2003).

Table 6 –1. The Joint Commission

Identifying and Addressing Patient Needs

Standard PC.02.01.21 The hospital effectively communicates with patients when providing care, treatment, and services. This standard emphasizes the importance of effective communication between patients and services. Elements of Performance (PC.02.01.21) 1. the hospital identifies the patient’s oral and written communication needs, including the patient’s preferred language for discussing health care. Note: Examples of communication needs include the need for personal devices such as hearing aids or glasses, language interpreters, communication boards, and translated or plain language materials. 2. the hospital communicates with the patient during the provision of care, treatment, and services in a manner that meets the patient’s oral and written communication needs.

continues Table 6 –1. continued

Providing Professional Language Access Services and Providing Information in a Manner Patients Understand

Standard RI.01.01.03 The hospital respects the patient’s right to receive information in a manner he or she understands. Elements of Performance (RI.01.01.03) 2. the hospital provides language interpreting and translation services. Note: Language interpreting options may include hospital-employed language interpreters, contract interpreting services, or trained bilingual staff. These may be provided in person or via telephone or video. The hospital determines which translated documents and languages are needed based on its patient population. 3. the hospital provides information to the patient who has vision support, speech, hearing, or cognitive impairments in a manner that meets the patient’s needs.

Access to a Support Person

Standard RI.01.01.01 The hospital respects, protects, and promotes patient rights. Element of Performance (RI.01.01.01) 28. the hospital allows a family member, friend, or other individual to be present with the patient for emotional support during the course of stay. Note: The hospital allows for the presence of a support individual of the patient’s choice, unless the individual’s presence infringes on others’ rights, safety, or is medically or therapeutically contraindicated. The individual may or may not be the patient’s surrogate decision maker or legally authorized representative. 29. the hospital prohibits discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression. Collecting Information on Language and Communication Needs Standard RC.02.01.01 The medical record contains information that reflects the patient’s care, treatment, and services. Elements of Performance (RC.02.01.01) 1. the medical record contains the following demographic information • The patient’s name, address, date of birth, and the name of any legally authorized representative • The patient’s sex • The patient’s communication needs, including preferred language for discussing health care. Note: If the patient is a minor, is incapacitated, or has a designated advocate, the communication needs of the parent or legal guardian, surrogate decision maker, or legally authorized representative are documented in the medical record.

Note. adapted from The Joint Commission (2010), Appendix C.

142 Adult Acute and Intensive Care in Hospitals 143

Patient Bill of Rights The Joint Commission Sentinel Events Report (The Joint Comission, 2013) identified three A key element of effective care in hospital set- primary causes of adverse events in hospitals: tings requires that patients be able to com- human factors, leadership failures, and communicate effectively with care providers so munication breakdowns. Also, data from these that doctors and nurses know when to adjust reports from 2004 to 2013 revealed that prob- medications, check intravenous (IV) lines, lems with communication were strongly asso- perform respiratory support procedures, ciated with events that caused patient deaths deal with urinary and bowel issues, position and permanent damage to patients. See http:// patients in their beds, and so on. The Patient’s www.jointcommission.org/assets/1/18/Root_ Bill of Rights (American Hospital Association) Causes_by_Event_Type_2004-2Q2013.pdf. is posted throughout most, if not all acute Researchers studying adverse events care facilities in the United States and can caused by medication-related errors have noted be accessed at http://www.aha.org/advocacy- that ICU patients are placed at risk when they issues/communicatingpts/pt-care-partnership are less able to actively participate in their care .shtml. It addresses informed consent, refusal (Bates ,et al., 1995; Cullen et al., 1997). Data to treat, power of attorney, and end-of-life also suggest that patients who have difficulty treatment directives. It specifically encourages communicating are three times more likely to patient-centered care and each patient’s par- experience an adverse medical outcome than ticipation in own treatment. other patient groups (Bartlett, Blais, Tamblyn, To remain active and engaged, some pa- Clermont, & MacGibbon, 2008). Investiga- tients need communication supports. While tors indicate that between 44% and 63% of specific accommodations are clearly mandated reported injuries were preventable, observing and regulated for some groups (e.g., people that more education and safety protocols are who are deaf and use sign language and people needed to achieve the Institute of Medicine with limited English proficiency), they are not target of a 50% reduction in harm (Kohn, Cor- specified for other groups (e.g., people with rigan, & Donaldson, 1999). Although more cognitive impairments, speech and language recent studies suggest a decrease in adverse impairments). In fact the Patient’s Bill of Rights events (that between 13.5% and 18% of hos- fails to specify explicitly the necessity of com- pitalized patients have experienced an adverse munication supports and accommodations event that caused temporary or serious harm), for patients with existing and acquired com- the incidence of adverse events is still too high munication impairments beyond American (Landigran et al., 2010; Levinson, 2010). Sign Language and non-English language translation/interpretation. Communication Vulnerable Patients

Sentinel Events Zubow and Hurtig (2013) reviewed de- identified (anonymous) medical records of Communication barriers are among the major all conscious inpatients over the age of three causes of adverse events in acute care hospi- at University of Iowa Hospitals and Clinics tals today. This includes, but is not limited to determine the percentage of their inpa- to, communication breakdowns or failures tient population who had medical conditions between health care providers and patients. that (a) restricted their ability to summon a 144 Patient-Provider Communication nurse (nurse call) and/or (b) restricted their (2015) examined electronic medical data from ability to speak with care providers because six adult ICUs across two UPMC hospitals in they required mechanical ventilation (e.g., Pittsburgh, Pennsylvania, and reported that spinal cord trauma, cardiopulmonary diseases, more than half (53.9%) of patients who were stroke, motor neuron disease, facial trauma). mechanically ventilated for two or more days To assure their sample response rates were sta- met the basic criteria for being in need of com- ble, the researchers examined inpatient data munication supports (awake, alert, responsive, for two, 7-day periods, separated by 6 months. or attempting to communicate during at least As shown in Table 6–2, 33% of conscious one 12-hour nursing shift). patients in ICUs and 14% of patients on other Although the findings among these three care units were unable to access or activate the studies reflect differences in sampling proce- nurse call system. In addition, 33% of patients dures and data collection methods, what is in ICUs and 7% of patients on other care readily apparent is that a significant number of units were unable to use their natural speech patients in ICUs and other hospital care units because of placement of endotracheal tubes are communication vulnerable. The need is and tracheostomies. A substantial number of clearly documented, as is the requirement that patients were not able to activate a nurse call hospitals identify, respond to, and ameliorate button or speak. The percentages of pediatric communication problems as they occur. patients and adult ICU patients needing assis- Patients with limited English proficiency tance were comparable. and those who are deaf also face significant Thomas and Rodriguez (2011) reviewed communication barriers. Unlike those with all ICU patients present on randomly selected other communication vulnerabilities, how- days, excluding patients with a history of ever, hospitals are being held to standards, speechlessness and those with preexisting use laws, and regulations that require them to or the inability to use adaptive communication inquire about a patient’s preferred language devices. They reported that 18.4% of adult and provide access to certified interpreters ICU patients were in need of adaptive com- (The Joint Commission, 2010). To get a sense munication devices. Happ and her co-authors of the utilization of interpreter services in a

Table 6–2. Conscious Patients Over the Age of Three Who Were Unable to Access the Nurse Call System or Speak Without Intervention at UIHC

Percentage Percentage (%) of Patients (%) of Patients Percentage Unable to Access Number of Unable to (%) of Patients Nurse Call Who Patients (Daily Access Nurse Unable to Use Also Could Not Average) Call Speech Use Their Speech Intensive care 91 33 33 19? units Non-intensive 386 14 7 1? care units

Note. From Zubow and Hurtig (2013). Reprinted with permission from Richard Hurtig. Adult Acute and Intensive Care in Hospitals 145 rural state versus a large metropolitan area, we The Interpreter Services Department at compared two programs. Tufts Medical Cen- UIHC reported 14,568 services for 46 differ- ter’s Interpreter Services Program reported ent languages between June 2013 and May providing 69,672 services in 2012 (inpatient 2014. Staff interpreters provided 61% of the and outpatient). A majority of language ser- services and the Language Bank of “as needed” vices (65%) were face-to-face encounters. interpreters provided 39%. Requests for Phone interpreters accounted for 34%. Most Spanish accounted for most (73%) requests. patient requests were for Chinese or Vietnam- ASL/Sign interpreting was the second most ese interpreters. (Note: Tufts is located near requested service. Table 6–3 presents the break- Chinatown in Boston, Massachusetts.) The down for the nine most commonly requested Tufts Interpreter Services Program translates languages at UIHC. regulatory and teaching tools into multiple languages, participates in rounds, and provides language charts on all units. Their patient-staff Psychological Impact of communication aid booklets, While Await- Communication Vulnerability ing the Arrival of the Interpreter, are bilingual (i.e., in English and in 10 target languages: The physiological, cognitive, and psycho- Arabic, Bosnian/Serbo-Croatian, Chinese, logical stress of a critical illness can cause Haitian-Creole, Italian, Khmer/Cambodian, and prolong symptoms of agitation, anxiety, Portuguese, Russian, Spanish, and Vietnam- depression, panic, and cognitive impairment. ese). They are used while awaiting the arrival Patients commonly report feeling helpless of an interpreter or during interactions when and a loss of control in hospitals unless they patients and staff exchange very simple, basic can communicate effectively with caregivers routine information. (Carroll, 2004; Magnus & Turkington, 2006;

Table 6 –3. Most Commonly Requested Language Interpreting Services at UIHC (2013–2014)

Number of Percent of Language Services Provided Services Provided Spanish 10703 73.47 ASL/Sign language 737 5.06 French 667 4.58 Arabic 543 3.73 Chinese 506 3.47 Swahili 419 2.88 Arabic 543 3.73 Bosnian 318 2.18 Vietnamese 311 2.13

Note. reprinted with permission of Richard Hurtig. 146 Patient-Provider Communication

Robillard, 1994; Bauby, 1997). The inability ponent of preventive action and thus lessen to communicate effectively during a critical the risk of PTSD. A useful online resource is illness contributes to feelings of distress, frus- http://icusurvivors.com tration, anxiety, and agitation (Khalaila, Zbi- dat, Anwar, Bayya, & Linton, 2011; Nelson et al., 2004; Rotondi et al., 2002). A new body Factors That Influence Effective of research is documenting an increase in post- Communication in Hospitals traumatic stress disorder (PTSD) in ICU survivors, such that some patients are reportedly unable to return to work even after achieving Many factors can influence a patient’s ability resolution of their medical problems (Girard to communicate effectively while hospital- et al., 2007; Griffiths, Fortune, Barber, & ized. Communication difficulties may occur Young, 2007). because of a patient’s medical condition, dis- To address these concerns, some critical ability, level of medication, and/or as a result care departments (cognitive psychiatry, physi- of a medical procedure, as well as environ- cal medicine, social work, pulmonology) are mental and social factors. O’Halloran, Grohn, now offering multidisciplinary follow-up for and Worrall, (2012) conducted a qualitative ICU patients after discharge to detect, pre- meta-synthesis review of health care workers vent, and treat post-ICU syndrome (Hernan- and characteristics of a hospital care unit in dez, Jenkinson, Vale, & Cuthbertson, 2014; an effort to identify environmental factors Modrykamien, 2012). Patients and family that either facilitated or created barriers to caregivers are counseled about resources and communication (Table 6–4). Although these the potential need for follow-up services. researchers focused on acute hospital stroke Reducing the communication barriers dur- units, their findings are relevant across all ing the ICU stay may well prove to be a com- points of care because they specify consid-

Table 6 – 4. Factors That Influence Effective Communication in Hospitals

Social and environmental Linguistic and cultural differences Health literacy Family caregivers and support persons Medical conditions: preexisting, Mechanical ventilation acute and temporary Sensory impairments Developmental and acquired chronic disabilities affecting speech and language Recent onset of neuromuscular paralysis and weakness resulting from injuries and illnesses Structural impairments (facial surgeries) Muscle weakness Significant cognitive disabilities Delirium

Note. reprinted with permission from Richard Hurtig. Adult Acute and Intensive Care in Hospitals 147 eration of the following variables: provider’s cultural and religious practices, beliefs about knowledge, communication skills, attitudes, illness and doctors/healers — these and many experience, individual characteristics, as well other factors can influence the success (or fail- as opportunities for communication, access to ure) of communication exchanges between communication aids and equipment, hospi- patients and providers. Environmental factors tal policies and procedures, staff training, and are often easy to modify or “fix,” while social physical environment within each care unit. factors are not, but they must be managed. In Based on their review of multiple stud- any case, we can help avoid many communica- ies, O’Halloran and colleagues concluded that tion problems by becoming more aware of the provider behaviors are central to the develop- complexity of communication, beginning to ment of communicatively accessible care units understand the impact of the environment and and recommended focusing on recruitment, provider’s behaviors on the communication retention, and ongoing professional develop- process, and learning to make good commu- ment of all health care providers in acute care nication a priority for every health care team. as a means by which to improve patient-provider communication. As discussed, hospitals are complex, Cultural and Linguistic Differences dynamic, high-stakes institutions, and many factors influence the success of patient inter- Communication can be particularly diffi- actions with providers. Table 6–5 summarizes cult when providers and patients have dif- areas that influence effective communication ferent backgrounds and views of the world, in hospitals. especially when they do not speak the same language. Differences in religious beliefs, culture, sexual orientation, gender identity, Environmental and Social Factors expectations about doctor/patient relationships, and family traditions can easily impact Lighting, noise, who sits, who stands, atti- patient-provider interactions. Anne Fadiman’s tudes, language barriers, family relationships, (1997) classic book, The spirit catches you and

Table 6 –5. Meta-Synthesis of Qualitative Research: Environmental Factors Influencing Communication Between Patients and Providers in Acute Hospital Stroke Units

Characteristics of health care Characteristics of stroke unit structure and processes providers Provider’s knowledge Opportunities for communication between patient and provider Provider’s communication skills Family Provider’s attitude Communication aids and equipment Provider’s experience Physical environment Provider’s individual characteristics Opportunities for staff to learn communication skills Hospital systems, policies, and procedures

Note. adapted from O’Halloran, Grohn, and Worrall (2012). 148 Patient-Provider Communication you fall down: A Hmong child, her American hospital length of stay and readmission rates doctors, and the collision of two cultures, illus- between non-English speaking patients who trates the disastrous consequences of culturally received professional interpreter services and bound communication breakdowns between those who did not, Lindholm and colleagues patients and health care providers. The book (2012) found that patients who received pro- chronicles the miscommunications between fessional language services had significantly health care providers and social services with shorter inpatient stays and fewer hospital the patient’s family and community that led readmissions. to the unfortunate removal of a child from the Most hospitals do not have medical inter- family and to a cascade of preventable medical preters on site 24/7. When on-site interpreters errors. Although everyone had the child’s best are not available for critical interactions, hospi- interests at heart, language and the prevailing tals can use telephonic, video, or Internet-based cultural differences contributed to the child’s interpreter services. For routine interactions ultimate death. associated with standard bedside care, some Medical sociologist Sharon Kaufman hospitals now use unit-specific communication (2005) conducted an ethnographic study of templates that have been vetted by professional dying in American hospitals. Her work details interpreters and created for many different lan- communication breakdowns and “incompre- guages. Examples of bilingual pages (Hurtig, hensibilities” between the health care system, Czerniejewski, Bohnenkamp, & Na, 2013) clinicians, and critically ill patients and their designed for use on speech-generating devices families/caregivers. Older adults are particu- are illustrated in Figure 6–1. larly vulnerable and often require family sup- The example shown in Figure 6–1A is port and surrogates for medical treatment to help Korean patients express feelings. All decisions during hospitalization. buttons are labeled in both languages. In the Consideration of generational (age) dif- low-tech version, patients can point to feelings ferences, cultural differences, and health lit- they want to convey. In the high-tech version, eracy is essential to the achievement of desired patients select a message that is then spoken medical outcomes. Putting information in in English so caregivers understand. simpler language does not guarantee better Figure 6–1B shows a bidirectional bilin- understanding. Family members often help by gual page set for Spanish-speaking patients so relaying information about a patient’s culture, they can communicate with English-speaking sensitivities, and preferences. In some situa- caregivers. The screen is divided into two tions, family members are asked to speak on halves. On the left side, buttons are labeled in the patient’s behalf. However, there are several Spanish and when selected produce an offi- reasons why family members should not be cially translated version in English. On the used as language interpreters during critical right side, the buttons are labeled in English interactions involving patient care. and when selected produce the message in Professional interpreters not only sup- Spanish. port interactions with patients who are For deaf patients who use American Sign non-English speaking or deaf, they typically Language (ASL) as their primary and preferred understand and reflect cultural sensitivities mode of communication, there is also an ASL that can promote authentic exchanges between version (Figure 6–1C). It has video clips of the patients and providers and contribute to bet- signed messages along with the corresponding ter patient outcomes. In a study comparing English message on the audio track. A

B Figure 6–1. A. Korean-English conversation page. B. English-Spanish-bilingual board. continues

149 150 Patient-Provider Communication

C Figure 6–1. continued C. American Sign Language display. Reprinted with permission from Richard Hurtig on behalf of the Assistive Devices Lab at the University of Iowa.

Health Literacy available on their website (http://www.npsf .org/for-healthcare-professionals/programs/ Understanding and acting upon health infor- ask-me-3/). However, utilizing these meth- mation to make health care decisions is com- ods is far more difficult when patients have monly referred to as health literacy. Poor health communication challenges, especially when literacy is associated with many negative health patients are unable to talk or write. It is there- outcomes (Hasselkus, 2011). Communicating fore important to provide alternative strategies in acute care hospital settings requires that that allow these patients who have difficulty providers use simple everyday conversational expressing themselves ways to demonstrate speech to describe medical conditions and understanding, so that they can take an active procedures to patients. In addition, hospitals role in their own care. should provide all print forms and information sheets in “plain” language. As discussed in earlier chapters, many hospitals use teach-back as Family Care Providers and Support Persons a required element of patient-provider interactions (Dantica, 2014; Dinh, Clark, & Bonner, Broyles, Tate, and Happ (2012) found that 2013). “Ask Me 3” (three questions patients family members often initiate the use of assis- should ask) is another method promoted by tive communication strategies with their loved the National Patient Safety Foundation and ones by supplying paper and pen, whiteboards, Adult Acute and Intensive Care in Hospitals 151 flash cards, or communication toys (e.g., Etch- Patients on Mechanical Ventilation a-Sketch, Magna Doodle, or Boogie Boards). Researchers have noted that some family During a critical illness, patients may require members are eager to be involved in augmen- respiratory support through mechanical ven- tative and alternative communication (AAC) tilation (aka, “artificial respiration”). Based on solutions. In addition, how well patients use national estimates, over 790,000 hospitaliza- recommended communication strategies dur- tions require mechanical ventilation annually ing a hospitalization often depends upon the in the United States (Wunsch et al., 2010). degree to which providers encourage them Two common methods of connecting the to do so. In other words, family members patient’s respiratory tract to mechanical ven- are willing to help; however, they need to be tilation are (a) endotracheal tube intubation instructed and coached on how to use specific and (b) a tracheostomy. An endotracheal tube AAC approaches (Broyles et al., 2012). is used when pulmonary support is needed The Joint Commission has now man- urgently and temporarily. During intuba- dated that patients in hospitals be allowed to tion, the endotracheal tube is inserted into designate a support person at admission, or the trachea through the mouth where it then later, if necessary. This person may participate passes through the larynx and vocal cords. It in both care and care planning. One role of a is secured externally by tape or commercially support person is to provide emotional sup- available holders. A plastic balloon is inflated port, which may also require making sure the to help keep the tube in place and maintain person has a way to communicate with hos- a seal between the oral cavity and pulmonary pital staff. Specifically, the Standard states the tract. The placement of an endotracheal tube following: and devices used to secure the tube can hinder oral motor movement making speech impos- sible and lip reading very difficult. “The hospital allows a family member, After endotracheal tube removal, the friend, or other individual to be present patient’s throat is often sore and the voice may with the patient for emotional support be soft or hoarse. Although these symptoms during the course of stay. Note 1: . . . usually resolve, some patients suffer perma- The individual may or may not be the nent vocal cord damage as a result of endotra- patient’s surrogate decision maker or legally cheal tube placement (Benjamin & Holinger, authorized representative.” (Element of 2008; Mencke et al., 2003). Performance RI.01.01.01) (The Joint When respiratory support is needed for a Commission, 2010, p. 61) prolonged period of time, surgeons often perform a tracheostomy (Esteban et al., 2000). Tracheostomy is a procedure completed under Medical Conditions: Preexisting, general anesthesia. During surgery, an opening Acute, and Temporary in the neck, commonly referred to as a stoma, is created below the larynx and vocal cords. In addition to environmental and social fac- The surgeon then places a tracheostomy tube tors, a multitude of medical conditions influ- in the stoma so air passes through the tube ence the ability of patients to communicate instead of through the mouth and nose. Since with doctors, nurses, other providers, and no air passes through the vocal cords, patients hospital staff. This section summarizes these no longer can produce audible speech. conditions and introduces some basic com- Although patients on mechanical venti- munication supports. lation are unable to talk, some patients with 152 Patient-Provider Communication a tracheostomy may be able to mouth words stand information (Pope, Gallun, & Kampel, after some training to enhance intelligibility 2013; Yorkston, Bourgeois, & Baylor, 2010). (Tate, Seaman, & Happ, 2012). Most of these All patients with sensory impairments patients use gestures to indicate “yes” and need access to their assistive devices to mini- “no” and can write using a pencil and paper, mize communication barriers. Unfortunately, whiteboard, Boogie Board, or tablet to gener- these aids are often left at home for fear of ate messages. Stovsky, Rudy, and Dragonette loss, or in trauma cases, they may have been (1988) reported on a randomized controlled misplaced or destroyed prior to arrival in the trial that examined the use of communication emergency department. Sadly, some hospitals boards in 40 postoperative cardiac surgical still instruct patients to leave their “valuables” patients. The patients who received commu- at home and discourage patients from bring- nication boards reported significantly higher ing sensory aids and other assistive technolo- satisfaction during the early postoperative gies with them. period than did those who received usual care (Stovsky et al., 1988). Similarly, critically ill, “Helen” is an elderly woman admitted ventilated patients with chronic obstructive to the surgical intensive care unit pulmonary disease (COPD) who had access subsequent to a fall at her skilled nursing to communication boards and paper reported facility. Her significant hearing loss was higher levels of satisfaction compared to the not disclosed at admission. She required control group who received routine nursing ventilator support after surgery, and communication practices (El-Soussi, Elshafey, because she was not very responsive, the Othman, & Agd-Elkader, 2014). However, nurses caring for her felt she might be some patients may need to use eye gaze point- cognitively limited. However, when her ing or switches to control devices that enable family was consulted, staff realized that them to select messages, as well as to activate the patient’s nonresponsiveness was more the nurse call, use bed controls, turn on/off likely due to her hearing loss. Writing lights and the television. Speech-language was not an option because she was weak pathologists work alongside nurses, pulmon- and had IVs in both arms. Also, she ologists, physicians, and family members to could not hold pen or paper and had help patients on mechanical ventilation com- difficulty seeing. municate effectively. Nursing asked the family to retrieve her hearing aids from the skilled Patients With Sensory Impairments nursing facility. After the nurse put in her hearing aids, “Helen” still was not Patients may be deaf and rely on sign language, responsive and was referred to the hospi- or hearing impaired and rely on hearing aids. tal’s speech and swallowing service for Patients may also be blind or visually impaired further assessment. A speech-language and use glasses, magnifiers, canes, and screen pathologist quickly determined that readers. Patients who are deaf and use sign Helen’s hearing aid batteries were dead language require certified sign language inter- and replaced them. However, within a preters. Many older adult patients have sen- few hours, the aids again malfunctioned. sory impairments because of physiological Helen was referred to an audiologist changes that affect their ability to hear and who concluded that “Helen’s” aids did see. In addition, noisy environments, such as not function well and prescribed new intensive care units, can make it more difficult hearing aids for her. for people with hearing difficulties to under- Adult Acute and Intensive Care in Hospitals 153

This case represents a “perfect storm” Family/patient information brochures can scenario. Helen’s hearing loss was initially not help family members remember to clearly disclosed. Staff at the skilled nursing center label eyeglasses and hearing aids and to notify had not properly maintained her aids. Unit nurses that these devices are in the patient’s nurses were not adequately trained to change room. Also, simple reference cards, resource the batteries and did not know how to assess guides, and bedside signage can help provide hearing aid function. Thus, solving this rela- nurses with the information they need to tively simple problem took days, during which care for devices (Hurtig, Stenger, & Wagner, time Helen was unable to participate in her 2014). Examples of bedside signage are shown care in any meaningful way. in Figure 6–2. When patients arrive without their personal aids and devices, families should be Patients With Developmental asked to bring them to the hospital as soon as Disabilities and Severe Speech possible. It is also critical that nurses receive and Language Impairments adequate orientation and in-service training on how to maintain personal devices, as well Patients with developmental disabilities may as learn about how to support communica- have impaired speech secondary to cerebral tion technologies provided by hospital staff palsy, autism, apraxia of speech, stuttering, or (e.g., assistive listening devices, magnifiers, other conditions. When their speech impair- electronic speech generating devices [SGDs]). ment is severe, these individuals often rely on

Figure 6–2. Bedside signage. Reprinted with permission from Richard Hurtig on behalf of the Assistive Devices Lab at the University of Iowa. 154 Patient-Provider Communication communication boards/books or speech gen- ments, and convey their personalities during erating devices (SGDs) to “talk.” A subset of the hospitalization. patients with developmental disabilities also have impairments or conditions that make it Patients With Acquired Disabilities difficult for them to understand spoken lan- That Result in Neuromuscular Paralysis guage, read, and/or write. Individuals with and Weakness Affecting Speech developmental disabilities learn to use a vast array of strategies, tools, and technologies Patients admitted to the hospital with severe over the years. When they are admitted to head trauma, cervical spinal trauma, cerebral the hospital, some will prefer to bring their vascular accident, or Guillain Barré syndrome personal aids and devices with them so they may be unable to communicate for hours, can maintain their independence and par- days, months, or even years without human ticipate actively in their care. Others may and/or technological supports. Depending decide to leave their devices at home. Instead upon where in the central nervous system these individuals may bring hospital-specific the damage occurs, patients may present with tools with them and/or ask a familiar com- paralysis of muscles that interferes with speech munication partner who understands their production, as well as gesturing, facial expres- impaired speech to accompany them. In any sions, pointing, and mobility. Patients with case, patients with developmental disabilities brain-stem strokes and spinal cord injuries, as need to be able to communicate with nurses, well as those with amyotrophic lateral sclero- doctors, other providers, and family members sis (ALS), may be “locked-in” (i.e., unable to throughout the hospitalization. move, but with cognitive and language abili- According to researchers in Australia, ties that are intact). hospitalized patients with developmental dis- Some neuromuscular conditions are abilities and complex communication needs progressive (ALS, multiple sclerosis), while face challenges expressing their needs, partici- other are chronic (stroke/aphasia, brain pating in their care, and remaining socially injury, spinal cord injury). Examples of com- connected (Balandin, Hemsley, Sigafoos, & munication tools that support these patients Green, 2007; Hemsley & Balandin, 2004). include low-tech paper and pencil strategies, Communicating with these patients may be communication boards and books, and high- a challenge for nurses and other caregivers tech speech-generating devices with eye track- unless they know what to do (Hemsley et al., ing capabilities. Downey and Hurtig (2006) 2001). There is strong evidence, for example, surveyed 133 experienced nurses working in that when these patients have effective com- ICUs and on a neurosciences inpatient unit. munication strategies, both patients and Table 6–6 shows that most nurses reported nurses benefit (Hemsley, Balandin, & Worrall, they had used a variety of communication 2011; Hemsley & Balandin, 2014). techniques with their patients. Specifically, Doctors can refer patients who are pre- they reported using adapted nurse call sys- scheduled for surgery or a medical procedure tems (98%), paper and pencil (96%), picture to speech-language pathology, audiology, or symbol boards (80%), alphabet boards and/or interpreter outpatient service depart- (65%), and lip reading (70%). Some nurses ments. The goals would be to develop strate- also reported using sign language (35%) and gies and materials that patients can use to ask electronic speech generating devices (46%). and answer questions about their conditions, Patients with acquired disabilities often express their needs and feelings, make com- face psychological as well as physical hurdles Adult Acute and Intensive Care in Hospitals 155

Table 6 – 6. Communication Strategies Used by Nurses in ICUs and on the Neuroscience Unit at UIHC

Percentage (%) of Nurses Indicating Communication Strategy Use of Strategy Paper and pencil 96 Picture or symbol board 80 Lip reading 70 Alphabet boards 65 Electronic voice output device 46 Sign language 35 Other 18

Note. reprinted with permission from Richard Hurtig. and may have difficulty adjusting to their dis- services to provide communication supports abilities (Hurtig, Downey, & Zubow, 2014). can sometimes help these patients achieve They are often seen by rehabilitation services a higher level of meaningful participation. (e.g., speech pathology, occupational therapy, Meltzer, Gallagher, Suppes, and Fins (2012) and physical therapy) during the admission. described a clinical ethics case of a 75-year- Many continue to need therapy to help with old homeless man with burns over 50% of his communication access, positioning, deter- body. He had no family or health care sur- mining vocabulary needs, representational rogate. He was awake, alert, ventilator-depen- systems, and other needs as they arise (Beuke- dent via a tracheostomy, and able to mouth lman, Garrett, & Yorkston, 2007). They can words, but had a history of mental incapacity. benefit from outpatient communication ser- After undergoing multiple operations, failed vices, monitoring, and team support through- skin grafts, and repeated infections over a out their lifetime (Beukelman & Mirenda, 1-year period, he required more surgery that 2013; Beukelman et al., 2007; Hurtig & he adamantly refused. The burn unit staff Downey, 2009). Chapters 8 and 9 address requested help from lip-reading interpret- health care services available to these patients. ers so they could better understand what he was trying to say, which greatly increased Patients With Significant the speed and fluency of critical discussions. Cognitive Disabilities With the help of lip-reading interpreters, psychiatry determined he lacked the capacity to Patients with cognitive disabilities secondary make informed decisions about eating, had to developmental, acquired, or degenerative poor insight into his medical situation, and conditions will usually have difficulty under- could not articulate the negative consequences standing what is happening to them during a of his desire to eat donuts and drink coffee, hospitalization. A referral to speech-language namely, aspiration and risk of death. Even so, 156 Patient-Provider Communication the patient was able to provide valuable input initiate communication and generate mes- about his preferences and share in decision- sages. Results from their study also suggested making processes. several barriers to effective device use: poor In commentary on the Metzler article, device positioning, a lack of staff familiarity Happ points out that although lip reading with SGDs, and patient preferences for other worked for the patient, it is not always success- methods. Patients with limited literacy skills ful or feasible. Despite his severe contractures, can use SGDs when provided with pictures or staff could have used communication boards symbols to create messages. with partner-assisted pointing technique as a More recently, Rodriguez and Bilschak viable option that would require little training. (2010) reported results from a study that sur- Alternatively, electronic speech-generating veyed patients with head and neck cancer, devices equipped with switch activation by a their family caregivers, and nurses. Their goal usable muscle group (face, lips, finger, or toe) was to determine whether patients had diffi- might have worked (Happ, 2012). culty communicating, what topics they found most difficult to communicate about, and Patients With Structural Impairments with whom they experienced the most difficulty. All groups agreed that effective com- Multiple structures are involved in produc- munication was essential during the acute ing intelligible speech. Trauma, congenital postoperative period. Patients reported hav- anomalies, and head and neck cancer surgery ing more difficulty communicating with reg- can interfere with a patient’s ability to speak, istered nurses than other groups. temporarily or permanently. For example, Whether a patient’s structural communi- mandibular fractures may require that the jaw cation impairment is short term or permanent, be wired to aid in recovery. Extensive head providing communication options immedi- and neck cancer surgery or radiotherapy can ately is critical. Writing tools (e.g., paper and cause temporary swelling that impairs speech pencil, whiteboards, and Boogie boards) may and impacts the patient’s ability to commu- work well for communicating face to face at nicate. Surgery sometimes results in perma- bedside. However, these methods do not allow nent structural changes that also may limit patients to communicate with family members oral speech. Patients who undergo a total lar- over the phone, by e-mail, or by text. Patients yngectomy will need alternative methods of often want to use familiar electronic devices, communicating until they can use a speech such as a smartphone, tablet, or touch pad to aid (e.g., electrolarynx) or tracheoesophageal communicate with family and friends. They voice prosthesis. may also benefit from using text-to-speech Happ, Roesch, and Kagan (2005) con- communication devices for environmental ducted a pilot study testing the feasibility control as well as communication. of electronic speech generating devices with 10 adult patients after head and neck cancer Patients With Delirium surgery during the postoperative in-hospital period. During communication observations, Delirium is a syndrome that commonly most commonly, patients relied on nonverbal occurs in acute and critically ill patients (Van communication (46%) and writing (31%). Rompaey, Schuurmans, Shortridge-Baggett, Only a small number (17%) used the cus- Truijen, & Bossaert, 2008). Delirium is de- tomized speech generating devices (SGDs). fined as a disturbance in attention and aware- However, those who did were more likely to ness occurring over a short period of time. Adult Acute and Intensive Care in Hospitals 157

Symptoms include cognitive problems, such ticularly susceptible, as are trauma patients as memory loss, disorientation, and psycho- who sustain burns and/or limb fractures. The motor agitation (American Psychiatric Associ- use of sedation for ICU patients on mechani- ation, 2013). In addition, respiratory disease, cal ventilation, which exacerbates delirium, older age, alcohol abuse, dementia, electrolyte can also quickly lead to a loss of muscle mass imbalances, severe illness, hypertension, fever, (Banerjee, Girard, & Pandharipande, 2011; opiate use (e.g., morphine), and metabolic aci- Morandi, Brummel, & Ely, 2011). dosis are predisposing or precipitating risk fac- Poor fine motor coordination and swell- tors for delirium (Van Rompaey et al., 2008). ing of hands and fingers can impair writ- Delirium is distinguished from demen- ing, reliable pointing to a communication tia by a sudden onset, fluctuating course and board, and touch screen activation. Patients reversibility. It is a serious complication of with muscular weakness secondary to muscle acute and critical illness, considered “brain atrophy may need assistance from commu- failure.” Delirium is directly associated with nication partners to spell, point, and use a poor short- and long-term outcomes among communication device. A helpful online re- critically ill adults, including prolonged source dealing with these approaches can be mechanical ventilation, longer lengths of hos- found at https://www.youtube.com/watch pital stay, in-hospital mortality, depression, ?v=D53gygWRhLM anxiety, and cognitive impairment after discharge (Brummel et al., 2014; Pandharipande et al., 2013; Wolters et al., 2014; Zhang, Pan, Communication Supports & Ni, 2013). The patient with delirium is unable to focus or sustain attention or wakefulness so As noted in the previous section, there are communication is impeded. Patients who are many reasons why patients in hospitals have delirious may have unintelligible speech, as difficulty communicating. While most hos- well as difficulty understanding and remem- pital systems make every effort to address bering. Nurses often recognize delirium and the communication needs of people with report their findings to the patient’s physician limited English proficiency and people who and other providers so steps can be taken to are deaf and require sign language interpret- ameliorate and remove causative factors. Cur- ers, the needs of other groups continue to be rent practices to address delirium include overlooked. getting the patient off sedation, weaning the Often, communication accommodations patient from the ventilator, and working to are quite simple, requiring only a slight modifi- engage the patient in communication (Balas cation to (a) the environment (turning on the et al., 2014). light, closing a door to limit noise, providing comfortable chairs) and/or (b) provider behav- Patients With Muscle Weakness iors (using “plain” language, establishing eye-to- eye contact, acknowledging there is a problem, Inactivity during an acute illness can con- modifying one’s positioning by sitting rather tribute to muscle breakdown and a decrease than standing, giving written materials in large in muscle mass and muscle atrophy (Casey, text, and so on). Sometimes, however, commu- 2013) causing upper extremity and oral motor nication solutions require special expertise and weakness and poor coordination. Patients necessitate the use of interpreter services and/ with heart disease and kidney failure are par- or collaborative teams of specialists who can 158 Patient-Provider Communication provide communication enhancement strate- Communication breakdowns can occur at gies, tools, and technologies. any point of care. Ultimately, however, hos- Communication specialists typically in- pital staff needs to know how to cope with clude speech-language pathologists, audiolo- communication breakdowns and how to gen- gists, and medical interpreters who have the erate referrals to appropriate services. The fol- unique knowledge and skills required to assess lowing story illustrates one patient’s journey and treat the unique communication problems from admission through discharge, highlight- that arise in hospitals (Blackstone, Ruschke, ing the communication supports he required Wilson-Stronks, & Lee, 2011; Rao, 2011). along the way.

Frank, age 26, was flown by air ambulance As part of the initial visit, the to the emergency room after sustaining speech-language pathologist demonstrated a severe spinal trauma due to a motor a speech generating device (SGD) and vehicle accident. A C3-C4 cervical spine explained how Frank could use it to injury left him unable to move his limbs. communicate. He looked down to indicate At admission, he was ventilator dependent, “no,” signaling that he was not interested. placed in halo traction, and taken to the Later in the day, however, when the team operating room to have a spinal fusion and asked if Frank wanted to control his TV further stabilize his cervical spine. and bedside fan using the SGD, he indi- When medically stabilized, Frank cated “maybe.” By the end of the session, was transferred to the surgical intensive he agreed to “give it a try.” care unit. He appeared alert and aware Because Frank was able to move his of his surroundings. However, he was tongue into his check, he could activate passive during interactions with his care a proximity sensor switch mounted on team, showing no interest in engaging the halo and positioned by the side of his with family and friends, exhibiting signs of cheek. The teams created a template so he depression. could call the nurse, ask for medication, Prior to his accident, Frank was an control a fan, and turn the TV off/on, energetic, physically active young adult using a simple serial scan method. He with a wide range of interests and a full demonstrated good control of the device. social life. He was characterized as a risk During morning rounds, nursing staff taker and someone who was not afraid to reported that he was practicing using the try new things. switch and device even when alone. Because he was orally intubated, staff Gradually, Frank became more generated a referral to establish commu- engaged with staff, family, and friends. His nication supports. The communication parents noted he had gone from a state of team found that Frank’s only intentional hopelessness to an understanding that he gesture was a gaze shift. He was able to had some control and power over his care. establish a reliable yes/no response, looking After a few days, Frank was adept at navi- up to indicate “yes” and down for “no.” gating through a full set of communication The team asked his bedside care staff to pages on the SGD. He used the device to offer him additional choices (“maybe” and regulate his care and express his feelings, “later”). turn the TV “on and off,” and select Adult Acute and Intensive Care in Hospitals 159

favorite channels. He also was working to his girlfriend while still in the ICU, and with his speech-language pathologist to they were later married. personalize some messages. He told her When Frank was discharged to a that he had a “proposal to make” to his rehabilitation facility, his greatest concern girlfriend. was being able to continue to use switches Gradually Frank transitioned from to control his environment. Arrangements the halo to a Miami-j collar, so positioning were made to purchase this equipment. of the proximity switch became another The hospital team communicated with the problem to solve. He liked wearing rehabilitation team to ensure that Frank’s baseball caps so the occupational therapist communication needs were understood decided to mount the proximity switch and could be met. Because of his ongoing on his cap. This allowed him to maintain needs, he was eventually transferred to a meaningful interactions with his family, long-term care facility. girlfriend, and staff. In fact, he proposed

Admission and Preadmission Admission staff or the admitting nurse can deal with many common communication Nonelective/unscheduled admissions like problems. These professionals show respect Frank’s are known as urgent/emergent hos- and sensitivity to patients from very different pitalizations. They are dictated by a patient’s backgrounds and know how to determine a medical condition and a treating physi- patient’s preferred language and modality of cian’s determination that a hospitalization is communication. They can identify any sen- required to address the problem. Generally, sory or motor deficits that may impact the urgent admissions cannot be postponed. More patient’s ability to understand and be under- than three-quarters (81.8%) of unscheduled stood by hospital staff. However, they are not admissions to hospitals now come through qualified to determine a patient’s cognitive sta- emergency departments (American College tus or decisional capacity, or to understand the of Emergency Physicians, 2013). Elective complexity of communication disabilities and (or nonemergent) admissions are “chosen by conditions that can interfere with a patient’s patients or their physician for a multitude of ability to talk, write, read, understand, and reasons that are perceived to be beneficial to remember during a hospitalization. Ideally, the patient, but are not urgent” (Rand Corpo- admissions staff should “tag” communication ration, 2013, p. 5). vulnerable patients immediately, so that care During the admission process, the com- staff are alerted and can generate an appropri- munication exchanges that take place are, for ate referral. the most part, fairly predictable. Patients need For elective admissions, the procedures to be able to provide information about their often begin in a doctor’s office. The patient symptoms, insurance matters, personal data, may subsequently receive general instructions medical history (e.g., allergies, complaints, about the hospital, what to expect while at current list of medications, etc.), advance the hospital, and what to bring to the hospi- directives, and so on. They also need to under- tal. Written documentation is supposed to be stand and respond to questions and read and provided in “plain language,” translated into complete required forms. languages of the local community, and made 160 Patient-Provider Communication available in accessible formats (Braille, auditory, rehabilitation professionals) can (and should) electronic) (The Joint Commission, 2010). help their clients prepare for scheduled and In emergent/urgent admissions, patients emergency-related hospitalizations in advance. may be unable to participate in the admission Individuals with preexisting communica- process due to their medical condition. Family tion challenges should have the following infor- members or medical surrogates may (or may mation ready to bring to the hospital: (a) personal not) be available to help. Regardless of entry and medical information; (b) personal assistive route, the information that needs to be col- technologies (e.g., hearing aids, glasses, com- lected is essentially the same. munication display, speech-generating device); Prior to a prescheduled admission, doc- and (c) written instructions to help nurses and tors can refer patients who have preexisting other care providers communicate with them communication challenges and patients who (e.g., This is how I communicate; These are may have difficulty communicating after a my assistive devices; These are the people who scheduled procedure or surgery to speech- can help me communicate with you). language pathology, nursing, and/or interpreter services for an outpatient visit. Goals of the outpatient visit are to (a) prepare the Care Units: ICUs and patient, (b) develop communication tools, Generalized/Specialized Care Units and (c) teach the patient (and family) how to use the recommended tools and strategies. After being admitted to a hospital, patients are Community professionals (e.g., speech- “triaged.” Elective and nonurgent patients are language pathologists in private practice, escorted directly to an appropriate general care

At age 35, John was diagnosed with a to communicate face to face with care laryngeal mass (head and neck cancer) and providers and family at bedside, but he scheduled for a laryngectomy. Prior to the also expressed an interest in commu- surgery, he met with an admissions nurse nicating with people at a distance. For and a speech-language pathologist. During example, he wanted to be able to “talk” the outpatient visit, the nurse reviewed his to the unit clerk over the intercom when history, discussed his upcoming surgery, he pushed the nurse call button. The and told him what to expect after surgery. speech-language pathologist then showed The speech-language pathologist explained him a simple SGD that would enable him that he would awaken with a tracheostomy to create messages and record his own and not be able to speak. John indicated he voice before the surgery. This is known as would prefer to rely on writing (e.g., paper message banking (Costello, 2000; Costello, and pencil, magic slate, word processing), Patak, & Pritchard, 2010). at least initially, because it would require The preadmission team also discussed little or no instruction. the possibility that John might emerge The speech-language pathologist from surgery with a partial or full glos- also showed John an electro-larynx but sectomy. They assured him that if that reminded him that he probably would were to happen, he would still be able to not be able to use it immediately because communicate. He said, “Okay, but let’s edema and bandaging would interfere. cross that bridge if we need to.” John said his immediate concern was Adult Acute and Intensive Care in Hospitals 161 unit. Emergent patients are typically taken n Problems caused by limited strength from the emergency department to another and/or motor control. patients who department in the hospital (e.g., radiology for are weak or unable to use their further tests, surgery to undergo an urgent hands may need a special switch so procedure) or to a care unit (e.g., medical, they can use an elbow, finger, toe, intensive care, cardiac, neurology, behavioral) or even eye blinks to activate the for further diagnosis and/or to treat their con- call system. Multiple switch options dition or illness. are available. Nurses may try a It is critical that unit staff quickly assess few switches and select and posi- each patient’s ability to summon help and tion one that works, or they may communicate with caregivers. The Com- request a consult from the hospital’s munication Access Decision Trees, pictured designated service, often speech- in Figure 6–3, illustrate the dynamic nature language pathology or occupational of communication challenges on care units. therapy. Once a reliable access Communication needs can change quickly, so method is identified, providers need anyone who is communication vulnerable will to monitor the patient’s use of the require ongoing assessment, monitoring, doc- alternative call button to evaluate umentation, and timely referrals. Figure 6–3A whether the system is adequate or focuses on accessing the nurse call button; needs adjustment. Figure 6–3B addresses all other communication needs. Figure 6–4 illustrates the crowded and complex environment of an ICU. It shows Accessing the Nurse Call System a simulated patient who is intubated and on mechanical ventilation, receiving nutrition When patients are unable to call for help, through a nasogastric tube, receiving fluids there is a notable increase in falls, injuries, and medication intravenously. He has an and other adverse events (Tzeng, 2011). As indwelling urinary catheter and is connected discussed earlier, on any given day, many to multiple monitors for vital sign functions. patients are unable to use a standard nurse It should be clear that accessing the traditional call button (Zubow & Hurtig, 2013). Reasons call system is a challenge for any patient in why patients may have difficulty accessing the this situation. standard call button include the following: Hospital safety protocols specify that all conscious patients be able to access a nurse call n Problems with positioning, restraints, system so they can effectively summon a nurse. or an inability to see the button. The standards for placement of nurse call but- Some patients cannot independently tons/cords are found in the AIA “Guidelines position themselves in bed, so for Design & Construction of Hospital and access may simply require proper Health Care Facilities,” 2001 edition (The placement of the button. When American Institute of Architects Academy of repositioning a patient, nurses and Architecture for Health, 2001). Hospitals need aides need to make sure patients can a system-wide protocol to identify, solve, and continue to use the call button reli- monitor problems when patients are unable ably. Family and visitors also need to access the standard nurse call system. This to remember to keep the call button is initially the responsibility of nursing staff, within the patient’s reach. but when solutions are not obvious, nursing 162 Patient-Provider Communication

B Figure 6–3. A. Nurse Call Decision Tree B. Communication Decision Tree. Reprinted with permission from Richard Hurtig.

can generate a referral to the hospital’s desig- Some hospitals post monitoring reminders nated service. outside a patient’s room and expect staff to Until patients can reliably call a nurse, look in on the patient. One example is the “no staff must monitor the patient very closely. pass zone” policy, which requires staff to enter Adult Acute and Intensive Care in Hospitals 163

Figure 6–4. Intensive care unit setup: simulated patient. Reprinted with permission from Richard Hurtig.

any room when a call light indicator is illumi- as “I don’t know” or “something else” are nated (indicating that the patient triggered the offered) are also not sufficient. They restrict call system). Signage can also be posted at the communication exchanges to predictable nurse call station so receptionists know which messages or messages that “meet a clinician’s a patients have difficulty using a nurse call system, priori expectations of a patient’s need,” but do and which patients have difficulty hearing, see- not necessarily meet the needs of the patient ing, speaking, understanding, or remembering. (Patak et al., 2009, p. 373). Effective communication in hospitals re- At Bedside quires that a range of options be made available to patients with hearing, vision, and speech Providers, hospital staff, patients, and family impairments, as well as other patient groups. members need to be able to communicate suc- For example, patients need to let nurses know cessfully with one another at bedside. Some when they are in pain, where the pain is, and patients require communication supports what the pain’s intensity is rated. Furthermore, (i.e., interpreters, designated support per- they need to be able to quickly report symp- sons, materials, and equipment) (Patak et al., toms that might indicate an adverse reaction to 2009). While mouthing words and relying on a transfusion of blood products or intravenous gestures and head nods can be helpful, these antibiotics, respiratory distress, or a need for methods are never sufficient for hospitalized suctioning. Figure 6–5 provides an example of patients. Likewise, patient responses to “yes/ a communication board that enables a patient no” questions (even when other options such to indicate pain or a need for suctioning. 164 Patient-Provider Communication

Figure 6–5. Pain and suctioning. Reprinted with permission from Richard Hurtig on behalf of the Assistive Devices Lab at the University of Iowa.

cation exchanges as limited, consisting pri- Patients with preexisting hearing, visual, marily of procedural-oriented information, or speech impairments may arrive at the commands, and reassuring statements (Ash- hospital with their own communica- worth, 1980). Reportedly, ICU nurses typi- tion aids or devices. For patients who cally initiate communication interactions with experience sensory or communication patients and direct the topic of communica- impairment due to their current medical tion exchanges (Ashworth, 1980; Happ et al., condition, it may be necessary for the 2011, 2014). Actual “conversations” tend to be hospital to provide auxiliary aids and a brief part of care interactions in ICUs (Ash- services or augmentative and alternative worth, 1980; Nilsen, Sereika, & Happ, 2013). communication (AAC) resources to Despite years of experience, even highly facilitate communication. (The Joint skilled, critical care nurses in ICUs cannot Commission, 2010, p. 41) always know what their patients are thinking, feeling, or wanting to communicate about. Communication in ICUs. ICUs are high- While it is easy to assume that patients are stakes, time-compressed environments (St. thinking about their pain or anxious about a Pierre, Hofinger, Buerschaper, & Simon, diagnosis and prognosis, that is not always the 2011). Researchers describe ICU communi- case, as illustrated by Susan’s story. Adult Acute and Intensive Care in Hospitals 165

Susan was recently diagnosed with cancer, Your medications?” Susan continued to and subsequently admitted for exploratory respond, “No, No, No.” Finally, the nurse surgery. Following the surgery, she was asked, “Do you want to talk about some- transferred to the surgical intensive care thing at home?” Susan nodded, “Yes.” Her unit (SICU) because she continued to daughter took over and eventually learned require ventilator support. A nurse noted that her mother was concerned about the that Susan seemed to be trying to commu- meat she had left in her refrigerator. She nicate with her daughter by mouthing did not want it to spoil. words, but it was not working. Susan was After that exchange the nurse went becoming increasingly agitated, so the back to her office. She recalled thinking, nurse decided to ask her to write down her “I am emotionally exhausted, but have message. However, Susan’s writing was not learned something very, very important. legible at the time, as shown in Figure 6–6. I had assumed I knew what my patients The nurse then began to ask Susan a want to talk about. I assumed Susan series of “yes/no” questions in an effort to was agonizing over her cancer diagnosis. narrow down what she was trying to talk Instead she was worrying about something about. “Are you having any pain?” Susan entirely different.” responded, “No.” Do you want to know During rounds, the nurse later told something about your condition?” Susan her colleagues, “I will never again assume answered, “No.” Do you want to know that I know what my patients want to talk about the tube you have? The ventilator? about.”

Figure 6–6. Unintelligible writing sample. Reprinted with permission from Richard Hurtig. 166 Patient-Provider Communication

Mechanically ventilated patients in ICUs ested in social interaction. Most want to be who do not have access to communication seen as a “person” not just a “patient.” Thus, options cannot report their symptoms (Pun- social exchanges with providers, however tillo et al., 2010). When they are provided brief, become a valued component of medical with communication supports, however, encounters in step-down units. interactions with nurses about symptoms Some patients want to tell jokes and increase (Happ et al., 2015), and they are discuss current events. Others want to catch more likely to become involved in decisions up on their family’s activities, ask about pets, about treatment options and discussions or engage in neighborhood gossip. These about end-of-life issues (Ankrom et al., 2001; patients are more likely to need ways to dis- Hurtig, 2012; Meltzer et al., 2012). Provid- cuss a range of topics that have nothing to do ing immediate communication supports to with their illness or condition. Figure 6–7 pro- conscious, alert patients in ICUs is not only vides an example of a “joke page” requested mandated by standards and best practice, but by a patient who wanted a way to “break the the right thing to do. However, having access ice” when interacting with nurses and family to communication does not necessarily solve members. “I don’t want them to see me as just all decision-making dilemmas. Patients who a sick body in the bed,” he said. use communication supports may express ambiguity or change their minds about life- Access to Equipment on Care Units. Hos- sustaining treatment decisions. pitals should have, or have access to, a stock of (a) alternative switches, (b) signage to place at Communication on Step-Down Care/Gen- bedside, (c) communication cards, (d) writing eral Units. While some interactions in step- implements, and (e) electronic devices. Some down/general care units are critical, others are hospitals have speech generating devices or more routine and more varied. They include tablet-based devices to help patients operate bedside assessments (e.g., neurological exam, environmental controls, access the Internet, explaining procedures), bedside procedures and “talk” with family and friends. Tablet- (drawing blood, changing an IV line, admin- based communication tools are ubiquitous istering medication), routine care (check- and thus often appeal to patients and staff. ing wound sites, feeding, toileting, ordering Devices that enable patients to access the food), social interactions (talking with fam- Internet and communicate with friends and ily and hospital staff), asking and respond- family from afar can make a difference in ing to questions, and engaging with people the quality of a patient’s hospital experience. in departments away from the care unit (e.g., Regardless of the technology, someone in the radiology for tests). hospital’s organizational structure needs to be Like patients in ICUs, these patients responsible for the acquisition, deployment, need a way to participate. They need to be and maintenance of these communication able to take an active role in decisions about tools. Table 6–7 provides a general overview. their condition/illness, report symptoms and It is essential that nurses in care units pain levels, express their unique personalities, know how to access and use equipment as well ask questions, and connect in other ways with as know when and where to refer patients if staff, friends, and family. They also need to needed. An example of a Referral Information be able to understand what providers are say- Chart is shown in Figure 6–8. Most referrals ing. Because these patients are not as sick or as are to speech-language pathologists, interpret- heavily medicated, they are often more inter- ers, audiologists, and occupational therapists. A

B Figure 6–7. A. Example of humor page: Knock-knock jokes. B. Example of humor page. Reprinted with permission from Richard Hurtig on behalf of the Assis- tive Devices Lab at the University of Iowa.

167 ad earing aids, glasses, low-tech communication earing aids, glasses, low-tech See Figure 6–2 Figure See Boogie Board, with Sharpie, Whiteboard notebooks, or text-to-speech keyboard; felt-tip pens, and orthotic aids clipboards, 6–1, 6–5, 6–7, 6–9, and 6–10 Figures See 6–4 Figure See H SGD device, personal computer, cards, smartphone, tablet/i P Example Light touch, proximity, pressure or infrared or infrared pressure Light touch, proximity, switches Blink bedside at • Readability • Language access • Understandability • Placement • Legibility • to tools Accessibility • to read Ability • visual, motor Access: • Training • Storage • control Infection • Storage • Maintenance • Tracking • control Infection • Privacy • Access • Storage • Safety • Access • Mounting • Reliability • Mounting • Dependability Considerations issues. communication about urtig. providers staff and visitors about communication needs and preferences communicate a broad range of messages in communicate a broad languages one or more communication options for expressive understand communication tools • general information to bedside Provide • literate to write patients who are Enable • quick way for patients to Provide • providing communication by Support • ability to hear/see/ patient’s Enhance • patients to use preferred Allow • access to nurse call Provide • access to communication tools Provide • Alert Purpose Example of Equipment to Support Communication Access in Hospitals Example of Equipment to Support Communication

H R ichard eprinted with permission from ospital provides ospital provides ospital provides ospital provides ospital provides lectronic devices (SGDs, lectronic atient’s personal devices atient’s Writing tools Writing H Nonelectronic communication tools (templates/displays, magnifiers H E listening devices, assistive tablets with communication apps, etc.) H P Type of Equipment Type Switches H Signage H Table 6 –7. Note. r

168 Adult Acute and Intensive Care in Hospitals 169

Figure 6–8. Referral information chart. Reprinted with permission from Richard Hurtig on behalf of the Assistive Devices Lab at the University of Iowa.

These departments need to respond quickly, hospital payments from Medicare (Jencks, access appropriate equipment, and solve the Williams, & Coleman, 2009). Thus, prevent- problem. ing avoidable readmissions not only has the potential to profoundly improve the quality Discharge and Beyond of life for patients but also protects the financial well-being of health care systems (Alper, Thousands of people are discharged from hos- O’Malley, & Greenwald, 2014). Current pitals every day. In 2006, for example, there health policy now incentivizes hospitals to were over 39 million hospital discharges in the significantly reduce length of stay and hospi- United States. Discharge planners work with tal readmissions (Shearer, 2010) by limiting patients, family members, health care provid- Medicare reimbursements for patients readers, and medical staff, as well as outside agen- mitted within 30 days. Because the risks of cies, to coordinate an effective transition from rehospitalization are highest when patients hospital to home or to another facility. are unable to communicate their symptoms, The importance of discharge planning participate in their care, and follow discharge is underscored when one realizes that among recommendations and instructions, successful Medicare patients almost 20% who were communication is a key component during discharged from a hospital were readmitted and after discharge from acute care hospitals. within 30 days. In 2004, these unplanned, Making decisions about where patients emergent readmissions cost the program go when they leave the hospital is not always $17.4 billion and accounted for 17% of total easy. These decisions involve consideration of 170 Patient-Provider Communication the patient’s (a) medical status, (b) needs for sents important legal and/or ethical issues follow up, (c) insurance coverage, (d) personal embedded in every hospital admission. Each preferences, and (e) ability of family members requires hospitals to make sure that effective, to manage or assist in postdischarge care. authentic communication between patients Social and environmental factors, as well as (or their surrogates) and providers/hospital community and patient/family supports and staff has occurred. resources, influence the discharge decision- While all patients can be involved in making process. decisional communication, decision mak- Conversations that take place during ing requires that patients have decisional discharge planning typically include a large capacity. By definition, “capacity” is differ- amount of new, difficult-to-understand ent from “competency.” “Competency” is a information. An effective discharge “hand- legal determination made by a judge in court. off” requires that information from the hos- “Capacity” is a clinical determination about a pital be clearly documented, communicated, patient’s ability to make a specific decision. To and understood. If patients go home, they determine “decisional capacity” requires that a (and family caregivers) need to understand functional assessment be made by “any” clini- how to carry out medication regimes, wound cian familiar with a patient’s case (Dastidar & care, and medical and therapy protocols, and Odden, 2011). However, not all clinicians are whom to call if they need help. This informa- qualified to conduct a capacity evaluation with tion needs to be written down and/or recorded patients who have difficulty communicating. using plain language and accompanied by Decision making for some patients may photographs, diagrams, or whatever else helps be complicated by strong evidence of impaired to increase understanding. Many hospitals thinking due to a critical illness (Cassell, Leon, conduct routine follow-up phone calls 24 to & Kaufman, 2001; Pandharipande et al., 48 hours after discharge, and some schedule 2013). Sometimes acute and critically ill pa- follow-up visits. tients are not included in decisions regarding Patients who do not go home are trans- their own care because of their “medical con- ferred to a rehabilitation facility, long-term care dition” and/or “communication difficulties,” facility, skilled nursing facility, or hospice. These rather than their “decisional capacity.” It can- facilities offer a continuum of care, the nature not be assumed that patients who are unable of which is discussed in subsequent chapters. to speak are also unable to take an active role in decision making. The “key components” of a capacity evaluation assume that patients Challenges have a way to communicate: n Communicating a choice. The Legal and Ethical Issues patient is able to make a choice, and the decision is stable enough for The language of medical encounters in hos- treatment to be implemented. pitals includes a wide array of terms includ- n Understanding. the patient compre- ing advance directives, pain management, hends information about treatment. informed consent, patient rights, do not Problems with memory, attention resuscitate orders, end-of-life decision mak- span, and intelligence can affect ing, and privacy: Each of these terms repre- understanding. Adult Acute and Intensive Care in Hospitals 171

n Appreciation. the patient is able to primary professional focus is the general appreciate the significance of infor- medical care of hospitalized patients), family mation provided. members, or providers without training in rel- n Reasoning. patients are able to weigh evant communication areas can make accurate the risks and benefits of treatment determinations. options, as defined by their personal Communication templates can be starting set of values (Merel & Murray, 2013). points for patients to participate in discussions about their condition and care. Figure 6–9 Effective communication is the passage- provides examples of templates that depict way toward determining decisional capacity. plans to resuscitate, ventilator support, dialy- Patients who are unable to speak, are deaf sis, and nutrition. Staff can tailor templates to and use sign language, as well as patients who meet the needs of individual patients. Tem- speak another language, and/or have diffi- plates should provide ways for patients to ask culty remembering and understanding infor- questions about procedures and the potential mation require specialists (speech-language consequences of any decisions they make. pathology, interpreter services audiology, psy- Mr. X provides a good example of the chiatry/psychology) to conduct the capacity importance of providing communication assessment. Hospital administrators cannot supports to ensure patients have decisional assume that “hospitalists” (physicians whose capacity.

Mr. X was 83 years old when he was quadriplegic. The other daughter insisted admitted to a surgical intensive care unit that because her father was an active and subsequent to a household accident that vigorous man who lived independently involved a cervical spine injury (C3-4). before the accident, he would not He was unable to move anything below want to continue on life support and his neck and could not breathe without become completely dependent on others. ventilator support. Once Mr. X was Throughout their discussion, Mr. X was stabilized, the doctor informed him and conscious, apparently following the discus- the family that his injury was irreversible. sion but unable to participate. The nurse Family members asked the ICU staff many decided to intervene. questions about the injury and about what The nurse asked Mr. X to show his options were available. The patient and daughters he could indicate “yes” and “no” family members were then left alone to reliably with his eyes. The nurse then asked absorb the news. him if he wanted to be part of the ongoing When one of the nurses returned, discussion. Mr. X quickly responded, Mr. X’s daughters were engaged in a “yes.” “Do you want to contribute to this heated conversation about whether their discussion,” the nurse asked. He again father would want to remain on ventilator indicated, “yes.” support. One daughter insisted her father The family was surprised and was a fighter and would want to do heartened by their Dad’s desire to everything possible to remain alive — even participate. They had assumed he might if it meant being a vent-dependent not even be aware of his condition. A

B Figure 6–9. Examples of pages that support discussion of general directives and resuscitation (A, B), ventilator issues (C), dialysis issues (D), and nutrition issues (E). continues

172 C

D Figure 6–9. continued Reprinted with permission from Richard Hurtig on behalf of the Assistive Devices Lab at the University of Iowa. continues

173 174 Patient-Provider Communication

E Figure 6–9. continued

The nurse arranged for a consult with keyboard page and partner-aided scanning speech-language pathology services to instructions. implement a simple communication Mr. X quickly became adept at using system so Mr. X could make his wishes this simple communication tool. He told known. The clinician provided him with his family that he did not wish to be kept a set of low-tech communication cards, on life support, but he did want more time including an alphabet board with instruc- to “talk” with each family member indi- tions for the nurse and family members vidually so he could explain his decision on how to use partner-aided scanning. and say good-bye. Figure 6–10 presents an illustration of a

A simple communication accommoda- one another after he died. He was able to dem- tion enabled Mr. X to express his decision and onstrate “decisional capacity.” He could state his his rationale for making it, giving him auton- preferences consistently over time and provide a omy. It also helped reassure him that his adult rationale that that was consistent with previous daughters would not be left hurt or angry with life statements (Merel & Murray, 2013). A

B Figure 6–10. A. Alphabet board. B. Instructions for partner-assisted scanning. Reprinted with permission from Richard Hurtig on behalf of the Assistive Devices Lab at the University of Iowa.

175 176 Patient-Provider Communication

Staff Training communication strategies and how to employ them to overcome communication barriers. Few preservice and in-service training pro- Researchers delineated the benefits grams or continuing education courses prepare of their online in-service tutorials and also health care professionals to support the diverse strongly advocated for on-site coaching and communication needs of today’s patient pop- guided practice as follow-up. One recommen- ulations. Nevertheless, the need to provide dation was small nursing “huddles” on care communication accommodations across the units to focus discussions and group problem spectrum of health care settings has never been solving around specific patients with commu- clearer. As discussed in Chapter 3, some train- nication challenges. The multifaceted approach ing programs are incorporating communica- of online tutorials and on-site practice may tion training protocols into their programs, help foster a “culture of communication” and and more resources are becoming available. encourage interprofessional approaches to Happ and colleagues tested a multicom- communication access problems. ponent communication intervention program with ICU nurses in the Study of Patient-Nurse Effectiveness with Assisted Communication Access to Equipment and Materials Strategies (SPEACS) (Happ et al., 2014). They studied a sample of 89 intubated, non- Challenges that currently interfere with the vocal patients who were awake and responsive deployment of communication equipment and 30 of the ICU nurses who were caring and related services in hospitals require admin- for them. The patients, whose nurses received istrative and department-level decisions. For training in “how to assess communication” example, who pays for the equipment? How and “how to support patients in the use of a is equipment stored, deployed, and tracked? variety of AAC tools,” showed significant im- How should infection control issues be man- provement (as compared to the control group) aged? How should Health Insurance Portabil- in successfully communicating messages about ity and Accountability Act (HIPAA) privacy pain (p = .03) and near significant improvement compliance issues be addressed? in communicating encounters about pain and other symptoms (p = .07). The research team n Funds for communication equipment. has refined their training program and made it Medicare and other medical insur- available as a condensed, 1-hour online train- ance companies expect hospitals to ing program and tool kit for nurses at http:// provide medically necessary devices go.osu.edu/speacs. SPEACS-2, a translational (beds, wheelchairs, IV poles and study conducted across six ICUs in two UPMC pumps) as part of the per diem bed hospitals tests the effect of the revised program charges, yet they do not reimburse on nursing care quality and patient outcomes directly for these items. Thus, hospi- (Happ et al., 2010). tals typically cover equipment and Downey (2014) also has developed an devices, known as durable medical online tutorial for nurses and speech-language equipment, through their capital pathology trainees. Both groups increased their budgets or fundraising efforts. knowledge about the communication chal- Because communication devices are lenges hospitalized patients face. Both groups considered durable medical equip- were also able to demonstrate knowledge of ment, providing communication Adult Acute and Intensive Care in Hospitals 177

equipment, while mandated, may be all personal information on hospital difficult. devices is electronically wiped out n Storing, deploying, and tracking once the patient no longer is using equipment. hospitals must estab- the device. lish policies that specify where equipment is stored and who is Infection control protocols should be responsible for ensuring that the approved by the hospital’s infection control equipment is functioning and that office, and the HIPAA compliance protocols maintenance and upgrades are should be reviewed by the hospital’s privacy performed. Equally important is officer and information technology staff. Both the tracking of equipment. Many sets of protocols must be developed with input hospitals have begun to use elec- from unit staff so that they are implemented tronic trackers attached to devices to with high fidelity. For patients who continue facilitate the tracking of devices and to need access to communication equipment prevent pilferage. devices after discharge, SLPs and social work- n Infection control. Infection control ers can help identify equipment loan programs issues are a major concern in hospi- or, in some cases, prepare reports that justify tals. When communication tools are the medical need for the device, so physicians not reusable because they cannot be can write a prescription to the patient’s insurer. sterilized, they must be discarded. Communication templates/displays could be sent home or transferred to Future Directions a receiving facility with the patient. For items that are reusable, a specific cleaning protocol must be established. The good news is that there is a growing aware- In addition, housekeeping staff and ness among hospital administrators, physi- unit aides need to know how to cians, nurses, and other health care providers implement the cleaning protocol. that effective patient-provider communication Figure 6–11A shows an example is an essential component of quality health of an SGD with environmental care and patient safety (American Medical controls, and Figure 6–11B pictures Association, 2006), as well as the basic right of a tablet mounted for use at bedside. every patient (The Joint Commission, 2010). n HIPAA compliance. having access With the advent of the Affordable Care Act to electronic equipment makes (U.S. Congress, 2010), reimbursement poli- it possible to customize message cies in the United States are increasingly tied content to meet the individual to measurable outcomes, patient satisfaction, needs of patients. Consequently, patient safety, and accountability, so hospital patients may store personal infor- leaders who understand how communication mation on hospital devices. Also, barriers impact these outcomes are more likely when hospitals make it possible for to explore ways to support systemic changes patients to use e-mail, social media, that address issues related to patient-provider online entertainment, and Internet communication. browsing on loaned devices, there Evidence already exists to show that poor need to be protocols that ensure that patient-provider communication leads to 178 Patient-Provider Communication

A B Figure 6 –11. A. Example of an SGD with environmental control capacity mounted for use at bedside. B. Example of a tablet mounted for use at bedside. Reprinted with permission from Richard Hurtig.

serious medical mishaps, increased health care The not so good news is that overcom- utilization, and poor patient outcomes (Divi, ing communication barriers in hospitals may Koss, Schmaltz, & Loeb, 2007; The Joint require a new way of thinking, behaving, and Commission, 2010). Research also demon- working within the system, or, in three words, strates that effective patient-provider commu- a “culture of care” that values successful com- nication increases the likelihood that patients’ munication throughout the hospital environ- problems are diagnosed correctly, that patients ment. To make this shift, all stakeholders from understand and adhere to recommended treat- administers to patient care personnel need to ment regimens, and that patients and families be involved. A “culture of care” needs to reward are satisfied with the care they receive (Wolf, staff for successful medical encounters, espe- Lehman, Quinlin, Zullo, & Hoffman, 2008). cially when they are difficult, and coach, not Improving patient-provider communication is punish, them when communication break- moving up the priority ladder. downs occur, so they can do better. Adult Acute and Intensive Care in Hospitals 179

Currently most hospitals systems in the How will hospitals respond to the new United States are not organized in ways that requirements, mandates, and fiscal impera- foster the kind of interprofessional collabora- tives driving the need for improvements in tion that is required. Instead, service depart- patient-provider communication? No one ments continue to operate in proverbial silos, really knows. However, as hospital systems each focusing on a body part or a specific func- strive to reduce costs and improve the quality tion of the hospitalized patient. Providers con- of patient care, safety, and medical outcomes, tinue to be driven by reimbursement strategies they will need to address communication bar- that reward number of procedures performed riers more directly and energetically. A simple and hours billed rather than patient outcomes immediate fix may involve putting low- to and value-based care. high-tech augmentative and alternative com- Finally on a positive note, The Joint munication tools on each hospital unit, but Commission’s Roadmap provides guidance on ultimately staff will need to know how to how a system-wide culture of communication deploy the right tool at the right time. Patient can be achieved, distributing the “burden” communication needs will have to be tagged across the entire organizational structure and across the continuum of care, and hospitals challenging administrators to take a leadership will need to launch new initiatives to promote role (The Joint Commission, 2010), as shown a true “culture” of communication care. in the sidebar.

Responsibility and leadership. Need to n patients who do not speak/under- identify “go to” services and staff, and stand spoken English (including develop easy-to-implement protocols patients who are deaf, deaf/blind, across points of care. blind) need interpreter services, alternative translations, and formatting of Electronic medical records. Need to tag and text materials. track a patient’s communication needs and n patients who are unable to access the preferences and accommodations (and call button need alternative switches, modifications of accommodations) made mounting equipment, protocols, and during the hospitalization. referrals to designated services, as necessary. Hospital-wide, interprofessional staff n patients who are unable to use training. Need to identify barriers to normal modes of communication communication and strategies for over- (for any reason) need referral to coming those barriers across points speech-language pathology/audiology of care. services and in some cases occupational therapy services to provide Resources. Need to have equipment, workable strategies and technolo- materials, signage, and protocols related gies, as well as to monitor effective to human supports available in multiple usage with providers, hospital formats to meet the broad range of patient staff, and family, throughout the needs across points of care. hospitalization. 180 Patient-Provider Communication

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