Transcript
Speaker: Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine. Sound provides comprehensive critical care programs to hospitals across the country.
Speaker: To learn more about our programs and career opportunities, visit www.soundphysicians.com. And now your host, Dr. Sergio Zanotti.
Speaker: Mechanically ventilated patients are unable to verbally communicate due to the endotracheal tube or tracheostomy, rendering them temporarily voiceless. In today's episode of Critical Matters, we will discuss communication with mechanically ventilated patients.
Speaker: This episode is part of a series of podcasts that are focused on different ways we can improve communication in the ICU. Our guest is Mary Beth Happ, a nursing distinguished professor of critical care research at The Ohio State University College of Nursing in Columbus.
Speaker: She's co-director of the Golden Buckeye Center for Dementia Caregiving and co-director of the T32 training in the Science of Health Development Program. a recognized educator and researcher with numerous publications in the critical care literature. Her areas of interest include patient care and communication during mechanical ventilation, family bedside presence during critical illness, end-of-life care and treatment decision-making in the ICU, and patient and family outcomes in acute critical illness. Mary Beth, welcome to Critical Matters.
Speaker: Thanks so much. It's pleasure to be here. So today we're going to talk about communicating with the voiceless patient on mechanical ventilation. Why should our listeners care about this topic?
Speaker: Well, simply because missed communication, misunderstanding, and misinterpretation of a patient's non-vocal message is a safety issue.
Speaker: Communication is foundational for the establishment of a relationship with the patient. And so that for me, that's first and foremost. but um but patient safety is certainly equally as important.
Speaker: Excellent. And I wanted to ask you little bit about your your research. and You have a very rich research trajectory that has focused on communication issues in the ICU. And I was curious if you could tell us more about this research interest and how it began. What made the the first spark for you to say, this is something I need to to solve?
Speaker: Well, it began with my doctoral dissertation where I focused on the problem of older adult ICU patients pulling on tubes and lines. um I did my research with...
Speaker: under the the mentorship of faculty at the University of Pennsylvania School of Nursing who were gerontologists and medical sociologists. and um The study was observational. While I had certainly experienced the problem as a clinician in the ICU, I wanted to put on ah an observer hat, notice what was happening both with the patient and with the nurses and other members of the healthcare team around this problem of pulling on tubes and lines. And it became...
Speaker: um obvious that these patients were unable to communicate vocally and that ah from the gerontology viewpoint, all behavior has meaning.
Speaker: And so understanding and knowing the meaning of the behavior was a way to help solve the problem. So the nurses who were able to um handle the patients reaching up for the tracheostomy or endotracheal tube by
Speaker: trying to find out what They were what the problem was. Oh, the tracheostomy site is itchy. but Let me change the dressing and make it more comfortable. Were the nurses who were able to treat it without sedation and physical restraint.
Speaker: And um so it became clear that communication and the inability to communicate, the voicelessness of the patient was a central problem. The medical sociologist on my um dissertation committee, Dr. Renee Fox,
Speaker: ah had been a polio survivor and she became passionate about the plight of these patients as I was ri as she read my field notes and said this is this is your what you have to do now this is your life's work and so it was Wow.
Speaker: No, and and you're right. And I think it's ah it's ah it's an example for our young listeners looking for career and research that observations of issues around you can really lead to a whole, like you said, life work of of digging deeper and deeper into into into a problem and trying to understand it and solve it.
Speaker: I would like to move on and talk a little bit about the experience of being voiceless from the perspective of a patient and what we know. Obviously, a lot of what we we we study and try to understand from our patients is not often done from a place of our own experience, but research and and other people's experience, although Many of our listeners and myself included have been patients and it's another way of of learning and and relating. And it's not uncommon, like you mentioned, the physician that was a polio survivor, that clinicians who go through critical illness ah develop a ah real and new insights and a level of empathy, right, that is very hard to get without that that experience. But if you could just give us a little bit more idea of what it means to be voiceless on mechanical ventilation for our patients.
Speaker: How does it impact based on what you've learned over these years? Patients tell us that it's frightening. They feel powerless. Mechanical ventilation is uncomfortable. And it's horrifying if they have no way to communicate.
Speaker: it's It's just that simple. And it's that those words are repeated in qualitative accounts, interviews, and ah statements that patients make after they experience.
Speaker: Absolutely. And and i I also, ah what we'll dig into this a bit deeper, but it's the other side of that equation, which is the caregivers. our impressions, our beliefs, and the myths that we tell ourselves around that patient might also make the the problem worse. But yeah before we get there, Mary Beth, from your experience, what are patients trying to communicate?
Speaker: What do they share as their biggest frustrations after recovery?
Speaker: Well... We can't assume that we know. and that's some of the problem is that we think we know the five things that the patient wants.
Speaker: All mechanically ventilated patients are going to want to communicate because think and they're mostly, um you know, physical things. And that's true. We do know that they're they're top five, you know, symptom complaints. That's discomfort around the tube um or in their throat, thirst. When will this tube come out? Am I dying? um Why am I here? I want to see my family.
Speaker: But the sum of what they communicate are things that we can't predict or know or the way that they're trying to tell us. um I mean, pick because they have never been without voice before and it's a new and and. um frightening environment they might choose words that we that are a little more difficult to guess right so or they might be asking us something that's outside of our of these five things or our list up for instance we had a patient become very agitated to ask if
Speaker: trying to ask if His wife had bought the Easter ham.
Speaker: that's That's not on the list, but it it was in his head and it was worrisome to him. People ask ah want to know about their pets um and and family. They want to know about things outside of the ICU.
Speaker: A patient wanted to ask for a raspberry ice. We might be able to understand ice, but raspberry is tough. um So there are, but there are simple ways to, to solve for that. What do they, what's their biggest frustration? um One that I see repeatedly, and you know, I'm on the communication bent here is call lights. So um patients, patients,
Speaker: might ah trip the collate and get a voice disembodied voice over the speaker in their room asking what they want and so they can't respond the patient can't respond and they may or may not get um the message across or someone to come in and
Speaker: find out more about what they need. And obviously the person responding is in the front desk, right, or whatever. And right and they're not aware that that that room actually has an intubated patient. And of course they can't tell you what what they need. so that we haves Sorry, go ahead. no go ahead We have seen some ICUs change that and have a system um for noting on the call light, which patients can't speak.
Speaker: the other thing that And that makes a difference. And I was going to, I was immediately thinking that I don't even know if my ICU has that, but that's an easy, that, that, that might be an easy fix, right? That makes sense. And that can save a lot of aggravation for a patient because the frustration of not being able to communicate, it probably just exacerbates so many other things. The other aspect that I would imagine based on my own experience is that when you're lying in a bed in an ICU, and it is amazing how you can focus on something that might be trivial for somebody else. And I remember an experience and not too long ago after 12 hours of general anesthesia and waking up very slowly.
Speaker: That at one point I was having all sorts of, don't want to say hallucinations, but a lot of discomfort and a lot of stress based on the pulse oximeter that was too tight.
Speaker: and And how do you communicate that, right? That that's what's what what's going on with my finger. And it was just a pulse oximeter that just needed to be changed, right? and As an example.
Speaker: I also believe that we have to include in our assessment of all this problem is that our patients might or might not have delirium, get all sorts of drugs that impact their disease.
Speaker: their mentation, even though we're getting better at that and we'll talk about that, that can also be a problem. But the other side of that is that voiceless does not always equal cognitive incapacity, right?
Speaker: And I believe that we we missed the boat here as clinicians. Can you talk about that? Yeah, absolutely. um i would say that cognitive capacity is a continuum and certainly often fluctuating in the ICU. have many case exemplars of patients with full decisional capacity or those with um capacity enough to contribute to treatment decisions and certainly to have credible um
Speaker: discussions about their treatment and credible responses around symptoms. d My impression is that we underestimate and how much our patients on mechanical intillation can really understand as clinicians.
Speaker: Is that fair? Yes, but yes and no. So I think clinicians correctly understand the patient's cognition fluctuates. um They aren't consistent or are highly variable validating patient's understanding.
Speaker: ah So we might um give information and so and assume that the patient understands um even a short command and without fully assessing understanding.
Speaker: Perfect. And we and we will we will discuss a little bit later if our assessment of their capacity to communicate, which I believe is an area that's very important. And you've done a lot of studies on that.
Speaker: and I wanted to ask you before we move on to... to studies on on this on this issue is over the last several years, there's been a lot of push with A to F bundles, ICU liberation, recognizing that we probably, we're not doing and our patients big favor with over sedation, with the excessive use of restraints, with keeping them and sedated for so long. And there's been really a push to try to decrease that. And I guess the,
Speaker: the the The byproduct of that is positive, but it also creates even more patients on mechanical ventilation who have the capacity to communicate, who are voiceless. Can you comment on that? Yes. i I'm hoping that because we have more patients who are more awake and aware that the message about supporting their communication is is going to...
Speaker: burgeon and reach um clinicians in ways that are are meaningful well programmatically because it really does take a whole um programmatic approach in the ICU. So the literature teaches us that having teams come together daily, reviewing the A through F, list and coordinating how they will implement the liberation plan is key. My frustration with the bundle is that I believe the C should be communication and that communicate, how the is the patient communicating um and what are we doing to support their communication so that everybody on the team knows and can use the same approach and not confuse the patient. um that this, I think communication should be an important part of that list.
Speaker: Excellent. Let's talk about some of the evidence behind this area of communication with the voices in the ICU. And because of changes in our practice, I would imagine that we're understanding more and more of the scope of the problem. We know how many people on average, or we can say site numbers of how many people get intubated in our ICUs in the United States. But when you look at the scope of the problem of patients who are truly capable of communicating but have it in the tracheal or tracheostomy tubes and are unable to do it through their voice. What's the scope of the problem based on the studies that you have conducted and your colleagues have conducted?
Speaker: Well, we found that in... at any given point in time, that 50% are, and this was yeah years ago before um the new sedation and ICU liberation guidelines have gone into effect.
Speaker: So, yeah,
Speaker: At least 50% of patients across a variety of specialty ICUs are able to communicate during windows, like for at least a shift um while they're mechanically ventilated and and usually longer. So communication support, communication assessment can be done patients at least half of your um mechanically ventilated patients. And i I say those numbers because, you know, there are some who have um
Speaker: quicker intubations, extubations. There are some who are more deeply sedated or have other neurocognitive problems.
Speaker: problems that make these communication supports not yet effective. But in some ICUs, and again, this study was done in 2009, so it's old, um they were or higher or greater.
Speaker: but But in any event, what it really tells me from a very practical perspective, Mary Beth, is that every single one of our listeners every day has patients where there's an opportunity to communicate and to enhance their communication and improve their overall care.
Speaker: Absolutely. So this means that this is extremely prevalent and it's part of our day-to-day every single time we step into the ICU. And I would also, these were just patients on mechanical ventilation that, but when you're thinking about all the i the patients in your ICU, i would suggest that most have a communication difficulty, a communication impairment.
Speaker: either because of the medication, because of their serious illness, because they have swollen hands, um ah so because they came in with communication, pre-existing communication difficulties, because they speak a different language, um because they forgot their glasses at home or their hearing aids. so there are a variety of communication impairments kind of on the continuum. And we can use this same assessment rubric for every patient in the ICU.
Speaker: Perfect. Could you tell us about SPEAKS and this approach and the the trials involved with it and and just teach us a little bit more about it? Sure. So it stands for the study of patient nurse effectiveness with assisted communication strategies. And um it's basically a systematic assessment of four main parameters, um cognition, language, and and sensory, meaning vision and hearing. Oral motor, can the
Speaker: patient is the patient orally intubated or have a tracheostomy or not intubated at all, but have other communication problems and their upper motor strength and use. And then the assessment funnels to four major categories of communication approaches or augmentative and alternative communication tools that can be used. With...
Speaker: So there are four major categories, but with some personalized differences as you do the patient assessment. So the origin story is i told you where I came to the problem in my dissertation work. And then my postdoctoral fellowship was spent exploring what was available, what has been done for this problem of ah patient communication or inability to communicate during mechanical ventilation. And I was attending the ah AACN conference and an electronic communication device was being um
Speaker: ah displayed as for use in the ICU. And that led me to the University of Iowa Speech Department, Dr. Richard Herding, who led the department and was a neuroscientist and tech junkie who was um taught me how to use some of these devices. So I pilot tested two devices with ICU patients. and and with post-op head and neck cancer patient or patients. And these were um devices, again, early two thousand that were typically used in the community setting with children who had developmental disability.
Speaker: I then partnered with um a speech language pathologist at Duquesne university. I was at university of Pittsburgh at the time, Dr. Catherine Garrett, and her work had been in the medical setting and um with patients with aphasia. And so we responded to a call um for
Speaker: studies on acquired communication disability. And we sold the notion that the the problems of communication in the ICU were acquired. And um the SPEAK study was a sequential cohort design, um meaning each cohort had a different um different treatment. The first was usual care and that was 30 patients and 10 matched with 10 nurses. So each nurse had three patients and we followed them over a two day period. The second cohort received um a four hour training um that Dr. Garrett and I developed
Speaker: um primarily from the speech language pathology communication sciences framework. And um the third cohort received, and and that was low tech communication supplies were delivered to the units. And the third cohort received a speech language pathologist evaluation and um,
Speaker: ah did The nurses received additional training in the use of these of electronic devices, and we had some electronic devices selected um for those
Speaker: And so what we found was that the two intervention groups had significantly greater success in communication about pain and improvement in other symptom communication, um improved nurse communication quality. The third cohort with the speech language pathologist and electronic communication devices had information augmentative and alternative communication tool use and more SLP consultations, less communication difficulty. So all all good outcomes. um
Speaker: And we learned from the, and this we video recorded, we observed and video recorded and then um coded the video recordings. It was pretty labor intensive, but fantastic study.
Speaker: And then we moved on to how can we implement this beyond just 10 nurses in a unit? How can we implement this unit wide? And um we knew that four hour trainings were too long um to implement unit wide. So we went to a one hour training online program using video recordings that we had garnered from
Speaker: the first speaks program. Now those video recordings are patient actors, but um they come straight from our first speaks study. And The Speaks 2 program was implemented across six ICUs and in two hospitals. And we showed improvement in nurse satisfaction and comfort with communication, less reported frustration on the part of nurses with patient communication difficulty. and
Speaker: Unfortunately, we weren't able to show impact on quality of care outcome measures, but did have qualitative reports of, no, I don't reach for the sedation. First, I reach for the communication tool. So, um and we can talk about the difficulties in in measuring outcomes for patients.
Speaker: an intervention related to communication. it's it's a little tricky. Yeah, it has its its challenges. But you mentioned something and that earlier you said that every behavior has a meaning, right? and that and and And I, over the years, have often seen that the patient is, quote, unquote, agitated, and we somebody goes for increased sedation.
Speaker: yeah And this and in this study and speaks to I mean, clearly what am what the nurses with better tools are able to do is to to pause and try to communicate first and understand what the problem was, because maybe the solution was not sedation. There was a better solution that would be beneficial for for the patient.
Speaker: Right. And so we were hoping to show reduced sedation requirements. um it the data didn't bear that out and realize that you have lots of different people in taking care of the patient and um and administering sedation. And while we got 85% nurses to take the training, you
Speaker: you can't control how many actually then implement that that with the patient at the bedside. And that's, you know, the rest of the implementation science work um that, you know,
Speaker: needs to be done to get the, cause it's a multi-level intervention, right? ah And i think that just expecting the nurses to be the ones who implement communication programs are, is is not enough. While they're the people um at the bedside 24 seven and communicating most,
Speaker: Frequently with the patient, um everyone at the bedside should have the same level, ah basic level of understanding augmented and an alternative communication.
Speaker: For sure. And everybody who's interacting with that patient needs to elevate their game, let's let's say it. But before me we move on to some practical advice, Mary Beth, what surprised you the most of the findings of these studies?
Speaker: um Well, the finding in the first study that
Speaker: we had greater success on communication about pain really surprised me because I thought that's what nurses did best and understood best with their patients.
Speaker: And um I'm going to give a caveat here. we measured the first three minutes of the patient nurse communication because that was a standard that we could apply across departments.
Speaker: nurse patient encounters that were video recorded. Some were short, some were long. um So nurses in that first cohort could have circled back around to an abandoned um communication about pain and eventually um
Speaker: found that or finished the communication or may had the communication be successful. But um these were an experienced group. So it I found it fascinating that we weren't getting pain right.
Speaker: and And like you said, something so basic that we usually imagine is the true area of expertise, right? That, oh, yeah, they can figure out if they're in pain. Mm-hmm. Absolutely.
Speaker: i would like the The jump was yeah was really surprised surprising and significant. Interesting. Well, like you said, we need everybody at the bedside to elevate their game. So one of the one of the goals, obviously, of of having you on this this this this episode was to create awareness, perhaps for some of our healthcare professionals,
Speaker: and ah colleagues who are not as in tuned to communication about pain and and and these studies as our nurses. And that includes our intensivists, our APPs who also interact with with patients who are mechanically ventilated on a daily and a daily basis. So as we we go into how to do it better,
Speaker: and I presume it starts with assessing the patient. How would you recommend that we assess our patient's capacity to communicate when they're on mechanical ventilation? Well, we recommend using our assessment tool. our um We have an algorithm um and a step-by-step assessment that really the
Speaker: the neurocognitive assessment that you are already doing, but um
Speaker: kind of channeling that specifically to how a patient is communicating and thinking about their communication capacity. So, you know, we ask if they can point um so And can they point to an an item on a communication board? So can they follow that command? Can they recognize the symbol? And can they use their pointer finger?
Speaker: Right? So it's... it meets several different assessment parameters. Can they, can they write, uh, holding a pen, to, to write, um, and first, you know, assessing their the first,
Speaker: step is assessing their yes no signal so um and is it consistent and reliable and if they're not able to use head nods what is there another signal you know you know um a finger tap or a um if and thumb in the fist or eye movements um We don't recommend hand squeeze because absence of hand squeeze. What is the absence of of.
Speaker: Of a hand squeeze, is that no or or just a weakness or not being able to do it so um That's not recommended. And that's, you know, I grew up on that. Well, that's my that's the most common thing I would imagine all my colleagues do, right? Squeeze my hand. yeah Right. Well, what if they can't? That doesn't mean, and I've had i've seen neurologists go into an ICU, you ask the patient,
Speaker: who is hemiplegic to squeeze their hand on the wrong side and then on the hemiplegic side and then say, Oh, there's nothing there. Yeah, for sure.
Speaker: bekeley so Really. so And the parent and the person's mechanically ventilated, you know, did have a stroke, but, um yeah could be assessed differently. and And one of the things that immediately comes to my mind, which I presume and you would also agree based on what I've read from your, from your, from, from publications that you have authored is the common myth that it takes too long.
Speaker: What takes, yeah what takes long is not communicating, right? Because we get into trouble. Right, right. um And it, Once you get skilled at it it doesn't necessarily take longer. It can be more efficient. um And so really being able to establish these skills is necessary for a credible assessment.
Speaker: So your assessment could be wrong if you don't use some of the methods to augment your message, to know if the patient can hear you or see you um ah correctly. So these things are all important. ah And Another myth that we carry in the ICU is that you can understand their, their lip movements.
Speaker: Um, and, or the, I'm a good lip reader. Well, our lip reading is a really, difficult, highly skilled, um,
Speaker: intervention. Yeah. I've never, there are professional lip readers. And even then you, you, you wonder, right. is right And, and they're not lip reading with people who have a tube in their mouth and a beard and toothless mouth. Um, so, and a very weak move, those weak tremory kind of mouth movements. so Um, that's why we say assessing oral motor movement, and you don't even assess the oral motor movement if they have a tube in their mouth, because...
Speaker: They shouldn't be mouthing around the tube. um It causes bronchospasm. It's not good. ah So only if they have a tracheostomy and ah using other um means first like a spelling board to along with mouthing words. We call that first letter spelling and ah always validating the message.
Speaker: Perfect. And i do I do believe that, like you said, a lot of times we we rely on it on on on handwriting on and and giving them some sort of board. My experience has also been that sometimes they're writing, you cannot understand anything they're writing, and it creates a lot of frustration. So having other tools, if that's not working, is also very important.
Speaker: And along those lines, I wanted to ask you if you could give us an overview of some some of these communication tools. i I think I read somewhere like people talked about no tech, low tech and high tech. I don't know that's a useful way of thinking of it, but it is if you could share with us some examples.
Speaker: So no tech are these strategies like the yes, no, establishing the yes, no signal um strategies for ah um for having the patient understand you And low tech are paper, pencil, felt-tip markers, simple communication boards, um glasses, hearing amplifiers, and um and then high-tech are electronic tablets and other kinds of devices.
Speaker: for For patients who can't write, electronic tablets, you can do finger writing, um on apps that amazingly patients who can't hold a pencil can oftentimes write legibly in ah an electronic finger drawing app.
Speaker: um So that's one of the ways that the electronic tablet can be used. And you might say, well, don't put a notebook and...
Speaker: belt tip marker next to the patient's bedside if they can't hold a pen, if they can't write. However, um ah part of these techniques, helping the patient understand you, involves you writing on the paper, giving them a visual, a list of keywords,
Speaker: as you're telling them um that they're they're going for a test and you'll be with them and um and the respiratory therapist will be with them and it's, will go in the elevator so that they understand and are or calmer about it, for example. And we also use the notebook notebook,
Speaker: for um written choices when we're trying to understand what they're trying to tell us. So if it's a category, you you you give them a category. or Are you asking me about your family? Yes or no? Yes. Okay. then um you write you know three selections about their family and and then the last selection is always it's something else ah so that they have kind of an opt out.
Speaker: And this is called written choice technique. And it's can be amazingly successful. one of the no tech um strategies that we recommend for people who are, you know, a little groggy, a little sedated or have delirium, when you so are using the yes, no technique, it's, it's called a tagged yes, no. And you're,
Speaker: your're asking the question, are you having pain? Yes or no. And you're also giving them the signal if it's head nods or thumbs up, thumbs in the in the fist for no. um You're showing them the visual signal and doing tagging the end of the question. and amazingly, it focuses the person to the end so that you don't get this,
Speaker: vacant or bobblehead response.
Speaker: Excellent. You mentioned family, and I wanted to ask you in a different context, what role does do families of our patients play in this whole communication and effort?
Speaker: Well, families are key, but unfortunately or unfortunately, sometimes clinicians defer to families to interpret the patient's non-vocal message.
Speaker: And their families may get it or may um understand an idiosyncratic gesture that the patient has. However, families have never played this pantomime game.
Speaker: ah This isn't the parlor game. ah These are high stakes and and very um stressful environments and families aren't any better at it than we are. And that's that's what they tell us. I don't know. i can't interpret what they're trying to say.
Speaker: ah And so they need the same communication support and guidance um that. that clinicians have ah ah or ah we're trying to avail for clinicians and some coaching in how to use ah the and help the patient use a communication Okay.
Speaker: And i think I think, Mary Beth, what what i'm what I'm listening and what I'm learning here is that, and I probably am guilty of and trying to get information, understand what a patient says. I don't understand the family members in the room. Ask them if they can help. I mean, if they can understand. And really, that's putting a little bit of an unfair pressure because they have no further expertise than and we do in this. And they're probably going to be as unsuccessful. But it's more about leveraging the tools and and really it's more about having an intentional a plan of how can we bring in tools to our bedside, low tech, no tech or high tech or all of them that can actually help us communicate better and better with our mechanically ventilated patients.
Speaker: Yes, and when we think about how stressful it is on families during critical illness and in you know the post-traumatic um time after critical illness, um families tell us, and this is the work of my ah colleague, Dr. Zhiyuan Shin, we um tested VitaTalk um app with patients and she
Speaker: specifically engaged families in what the experience was like using um this electronic app with patients and they said it opened up commit the communication that it was um you know it was really significant emotionally powerful to be able to understand their patient um now the caveat is they can't always see sometimes it's just a window of when they're good enough cognitively to use the app but um even those windows they were very appreciative of
Speaker: Excellent, and we'll definitely link a the studies and the VitaTalk app so people can explore a little bit more on the show notes. We talked about practical advice for the individual clinician.
Speaker: want to hear a little bit more about building a communication-friendly ICU as we design our ICUs and try to improve them. If you were designing an ICU from scratch, Mary Beth, what would be different if in that ICU to improve communication with our patients, especially those on mechanical ventilation? Yeah. Yeah.
Speaker: Well, we've already talked about one, and that is that the call lights would be equipped with a signal that the patient is unable to speak or unable to hear or has vision problems. um oh Electronic tablets or computer access to communication apps would be built in. and I think some of the newer ICUs do have that. um I think those are the main things
Speaker: the other The other piece would be having a and this is a systems issue, maybe not a build issue, but it is a systems design that there would be a communication cart, a communication cupboard where that is stocked and inventoried for um communication simple communication boards, um And other supplies ah like the notebook and the felt markers that are available at the on the units for clinicians to have to use um with patients at the bedside. And what we found in implementation of these communication programs is...
Speaker: after after we leave and in the sustainability phase, the the problem area comes with, well, who's responsible for inventorying and st stocking? And and does it go on the speech language pathology um cost center? They don't really usually have a cost center or nursing or where does it lie?
Speaker: And so um the build, the design would, it in my perfect world, would have that figured out. Excellent. Daily rounds in the ICU are an important motor for advancing care for our patients on as they journey through their critical illness.
Speaker: You mentioned about changing or adding communication to the SIA and the A to F bundles. What else could we do during rounds and or leverage rounds, and what are the ways to improve communication with mechanically ventilated patients?
Speaker: Yes, definitely making it part of the checklist, part of what is discussed. um Having speech language pathology consults for communication support be um ah more routine. Sometimes that varies from institution to institution, depending on their capacity the in that department. But um
Speaker: note Sometimes it's a surprise to clinicians that SLPs can be consulted for communication support, not just swallowing evaluation.
Speaker: Excellent. As we close the clinical topic, I would like to get a ah clinical pearl and a pitfall to avoid. And from an intensivist or a clinician or a nurse perspective, what is one thing that we should stop doing with these patients? And what is one thing that we should start doing with these patients?
Speaker: Well, I've already talked about some of the assumptions that we should stop making that we are We are good lip readers. We know what the patients want to say. And and we should stop limiting communication to just yes, no questions because we can't then we control the message and the and the topic. And we're missing what patients what novel message patients might be needing to tell us.
Speaker: um and limiting communication for the intensivists, um really recognizing that communication is a two-way street. So um being able to learn the techniques so that and and and require this level of practice in their ICU. Yeah.
Speaker: what I'd like to see. Excellent. is there Is there one misconception about communication with ventilated patients that you would most want to eliminate? That the patient is not ready to communicate.
Speaker: i hear that. They're not ready.
Speaker: That is perfect. And... I'd like to close the podcast, Mary Beth, with a couple of questions that are unrelated to the clinical topic. Would that be okay? Sure.
Speaker: So the first question relates to to books. Is there a book that you have read recently or in the past that has had a great impact on you? Well, I like to read nonfiction. um So the book that I've read recently that's had an impact is Culpability by Bruce Hallsinger. that's a novel ah about ai And it's not futuristic. it's So it really gives us um lots of food for thought.
Speaker: Well, definitely. I have not read that, but it sounds intriguing. So we'll look we'll look it up. The second question is about changing our minds. If you could share with us something you changed your mind about in the last couple of years.
Speaker: I think that um this is a hard question. I think I have um
Speaker: been less... I've... learned some grace and giving others grace um over the last couple of years. And I, at least I hope so. um And I've realized that I sometimes have taken um colleagues for granted. And so I've changed my mind about that.
Speaker: Excellent. i think that all of us a can give not only others, but our ourselves more grace, probably. Right. And it's that self-compassion and compassion to others that ultimately helps us move forward in our relationships, but also just navigate the world. So that that's a great one. And to finish, is there something you would want all our listeners to know could be a quote, a final thought on the topic or something else?
Speaker: Yes, so communication behaviors are habituated. They're really learned um over time and require deliberate thought and practice to change. Even though it's not rocket, none of these techniques and what I've told you in the past hour is rocket science. We have to recognize that they are habit and requires some deliberate thought and practice to change.
Speaker: and And the other message is engage with speech language pathologists early and often for communication support. It's reimbursable. Perfect.
Speaker: Mary Beth, you've given me a lot to think about on my daily practice. As we were mentioning before we started recording, this is one of those areas that impacts our practice on a daily basis, yet a lot of clinicians like myself have not really given it deep thought.
Speaker: And as you've demonstrated with your wonderful research and all the the studies you've done, there's a lot we can be doing better. that will have a real impact on the patients. And I think it's an obligation to to up our game. So thank you so much for sharing your expertise with us and your time. And I look forward to having you back on the podcast to talk about this or other topics.
Speaker: I'd love to. Thanks. Thank you for listening to Critical Matters, a sound podcast. Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
Speaker: Sound's transforming the way critical care is provided in hospitals across the country. To learn more, visit www.soundphysicians.com.
